Cardiovascular disease continues to place a significant burden on individuals, communities and the Australian health system. While prevention and early detection are widely recognised as priorities, they are not yet consistently embedded in everyday primary care. Nurses are uniquely positioned to bridge this gap, yet their role in prevention-focused cardiovascular care remains underutilised. This review brings together 30 years of Australian evidence to better understand what works, and where we are still falling short.

A systematic review of randomised controlled trials published between 1995 and 2025 was conducted across major databases and clinical trial registries. Twenty-one studies (n=9,815 participants) were included, most focusing on secondary and tertiary prevention, with only two addressing primary prevention. Across these studies, nurse-led interventions consistently improved system-level outcomes. Participants experienced more days alive and out of hospital, shorter hospital stays (by 6–12 days), and reductions in healthcare costs of up to 40%. Some improvements in clinical measures such as weight and HbA1c were observed, although changes in lifestyle behaviours and mortality were limited.

What stands out, is not just what works, but what is missing. There is very little evidence of nurse-led approaches in primary prevention, and limited attention to rural and underserved populations, where the need is often greatest. This points to a clear gap between what we know and what we do.

Moving forward, there is an opportunity to rethink how cardiovascular prevention is delivered in Australia. Scaling nurse-led, risk-stratified approaches within primary care, particularly in rural and regional settings to support earlier identification, reduce avoidable hospitalisations, and improve quality of life. Translating evidence into practice will require not only policy support, but a shift in how we value and embed nursing roles within prevention-focused care.

References:
Beks, H., Clayden, S., Shee, A. W., Binder, M. J., O’Keeffe, S., & Versace, V. L. (2023). Evaluated nurse-led models of care implemented in regional, rural, and remote Australia: A scoping review. Collegian, 30(6), 769–778. https://doi.org/10.1016/j.colegn.2023.05.004

Carrington, M. J., & Stewart, S. (2015). Cardiovascular disease prevention via a nurse-facilitated intervention clinic in a regional setting: The Protecting Healthy Hearts Program. European Journal of Cardiovascular Nursing, 14(4), 352–361. https://doi.org/10.1177/1474515114537022

Background:
Antimicrobial resistance is predicted to overtake cancer as the leading cause of death globally by 2050. Antibiotic use is common in early childhood and unnecessary exposure can contribute to the development of bacterial resistance. Educational interventions engaging children and families may help improve understanding of responsible medicine use and support children’s emerging role in health decision-making.

Purpose:
To design and pilot a pharmacist-led, play-based learning intervention (SlimeLab) for children and their carers and, evaluate program delivery by identifying key enablers and tension areas.

Methods:
SlimeLab utilises slime as a tactile tool, with the core activity representing the accumulation of mutations and following a structured format that prompts participant decision-making. Program content was developed by a pharmacist and quality use of medicines researcher using public health resources and reviewed by two external experts in paediatric pharmacy and general medicine.

SlimeLab was first piloted in Adelaide, South Australia during Australia’s National Science Week 2025. Subsequently, an external expert in science communication and educational design observed three additional sessions to evaluate delivery and identify enablers and tension areas.

Results:
The program was delivered for children aged ≥8 years and their carers across six sessions with a total of 39 participants. Enablers included the facilitator’s expertise in pharmacy practice and quality use of medicines, the narrative format helped break down complex concepts into relatable actions and tactile slime-based activities modelled scientific ideas supporting embodied learning and connecting concepts to action. Tension areas included, a dichotomous “right/wrong” decision format, some content required higher-order thinking beyond the developmental level of the audience and parental involvement was sometimes limited due to cultural expectations.

Conclusion:
SlimeLab was perceived as well positioned to support the development of skills and agency enabling children to engage with decisions about their own health.

Objectives:
To evaluate changes in specialist outpatient referral characteristics and waiting times before and after the onset of the COVID-19 pandemic in a regional Australian health service.

Methods:
A retrospective study used routinely collected administrative data from Central Queensland Hospital and Health Service. All patients attending at least one public specialist outpatient consultation between January 2017 and December 2023 were included. Periods were classified as pre-COVID (January 2017 to February 2020) and post-COVID (March 2020 to December 2023). Outcomes were waiting time from referral to first appointment, referral urgency, consultation mode, and specialty distribution. Interrupted time series and mixed-effects regression models examined immediate and ongoing impacts of COVID-19.

Results:
A total of 159,556 specialist outpatient consultations were included, with similar numbers pre-COVID (n=79,779) and post-COVID (n=79,777). After COVID-19, urgent (≤30 days) referrals increased from 40.3% to 46.7%, while non-urgent referrals declined from 15.2% to 10.7% (p<0.001). Mean in-person waiting time increased from 95.0 days in 2017 to 164.8 days in 2023, and the 95th percentile rose from 357.0 to 812.1 days. Ophthalmology had the longest median waiting time (140.0 days, IQR 41.0–377.0), while psychiatry had the shortest (8.0 days, IQR 3.0–27.0). Interrupted time series analysis showed sustained post-COVID increases in waiting times, with median waiting time rising by 0.4 days per month (p=0.001) and mean waiting time by 2.1 days per month (p<0.001). In adjusted mixed-effects models, waiting time increased immediately by 168.6 days (95% CI 164.7–172.5) at COVID onset and continued to rise by 17.3 days per quarter thereafter (95% CI 16.8–17.7; p<0.001).

Conclusions:
Specialist outpatient waiting times in regional Queensland increased substantially following the COVID-19 pandemic, with marked variation across specialties. These findings highlight persistent system pressures and the need for targeted strategies to improve timely access to specialist care.

Background:
While cigarette smoking has declined in many countries, nicotine exposure persists through the use other non-combustible products. These products are increasingly used by young people, yet nicotine use among amateur and university athletes remains under-examined. Emerging evidence suggests that the subjective effects of nicotine may be interpreted as compatible with performance-oriented sporting environments. This scoping review maps peer-reviewed evidence on the prevalence, patterns, and reported reasons for nicotine use among amateur and university athletes.

Methods:
A scoping review was conducted following JBI methodology and reported in accordance with PRISMA-ScR guidelines. Systematic searches of MEDLINE, Embase, CINAHL, Scopus, SPORTDiscus, and Web of Science were undertaken for studies published from 2019 onwards. Eligible studies involved amateur or university athletes and assessed use of non-combustible nicotine products, including e-cigarettes and smokeless tobacco. Screening and data extraction were conducted using Covidence and a customised extraction template.

Results:
Twelve studies met inclusion criteria, predominantly cross-sectional, conducted in high-income Western countries. Nicotine use was generally higher among male athletes. While e-cigarette use was more prevalent among younger athletes, smokeless tobacco use was more common among older participants and within specific sports. Higher prevalence was observed in team and contact sports compared with individual sports. Reported reasons for use included peer influence, social identity, perceptions of reduced harm, and functional purposes such as performance, coping, and smoking cessation. Several studies reported nicotine use occurring in close temporal proximity to training or competition.

Conclusion:
Sport participation may reduce cigarette smoking, yet this protective association does not consistently extend to non-combustible nicotine products. Nicotine use among amateur and university athletes appears embedded within social and performance-oriented sporting cultures rather than reflecting indiscriminate risk-taking. These findings highlight the need for sport-specific prevention strategies that address misperceptions regarding the harms and performance compatibility of non-combustible nicotine products.

Aims:
To explore barriers and enablers influencing access to specialist outpatient appointments in Central Queensland Hospital and Health Service (CQHHS).

Methods:
A qualitative study was undertaken using semi-structured interviews with key CQHHS stakeholders. Participants were recruited through CQHHS staff email networks, the General Practitioner Liaison Officer, consumer advisory groups, and social media. Fourteen participants completed interviews: specialists (n=3), general practitioners (n=3), nurses/administrative staff (n=5), and patients (n=3). Interviews were audio-recorded, transcribed verbatim, and analysed using a framework approach informed by the Consolidated Framework for Implementation Research (CFIR).

Results:
Seven major themes were identified: (1) workforce challenges, including specialist and nursing shortages, delayed accreditation of overseas-trained doctors, and burnout; (2) referral system quality, including incomplete referrals and limited uptake of electronic Smart Referrals; (3) structural barriers such as funding and infrastructure constraints; (4) COVID-19-related disruption and persistent backlogs; (5) patient impacts, including clinical deterioration during prolonged waits; (6) organisational culture and inter-professional communication; and (7) short- and long-term improvement strategies. Participants reported waits exceeding 900 days for Category 2 ophthalmology appointments, with associated vision loss, and delays of 3–4 months in referral categorisation leading to Category 1 breaches before formal waitlisting.

Conclusions:
Access to specialist outpatient care in regional Queensland is constrained by interrelated workforce, referral, and system barriers, compounded by ongoing COVID-19 backlogs. These findings highlight the need for coordinated reforms to improve referral processes, strengthen workforce capacity, and reduce delays that may lead to avoidable patient harm.

Background: Adolescent e-cigarette use has increased globally, prompting calls for effective interventions to prevent e-cigarette uptake and support cessation. However, evidence regarding the effectiveness of such interventions remains limited, restricting the ability of policymakers and practitioners to identify and invest in evidence-based approaches to address adolescent e-cigarette use at a population level.

Aim: To conduct and maintain a Cochrane living systematic review evaluating the effectiveness of interventions to prevent and cease e-cigarette use among children and adolescents aged ≤19 years.

Methods: This review aligns with Cochrane living systematic review methods. We searched CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, Europe PMC, and trial registries in September 2025. Eligible studies employed randomised controlled trial (RCT) designs to evaluate interventions targeting e-cigarette prevention or cessation among adolescents (aged ≤19 years), compared to usual care, no intervention, waitlist, or alternative interventions. Outcomes included e-cigarette ever-use and current-use ≥6-months post-baseline. Risk of bias was assessed using Cochrane RoB 2 tool. Random-effects meta-analysis was conducted where appropriate.

Results: Three studies involving 10,510 participants were included. Two cluster-RCTs evaluated school-based prevention interventions, while one RCT evaluated a text-message intervention to support adolescent e-cigarette cessation. Meta-analysis of two prevention studies found interventions may reduce e-cigarette ever-use compared with usual care, although evidence was very uncertain (RR 0.94, 95%CI 0.89–0.99; 5306 participants; very low-certainty evidence). One cessation study found a text-message intervention likely reduced current e-cigarette use among adolescents (RR 0.73, 95%CI 0.65–0.82; 1064 participants; moderate-certainty evidence).

Conclusions: Evidence to inform policy and practice regarding interventions to prevent or cease adolescent e-cigarette use remains limited. Current evidence suggests text-message cessation interventions may be effective and could represent a scalable approach to support cessation, while evidence for prevention interventions remains uncertain. Ongoing trials are likely to strengthen the evidence base and better inform future public health investment and policy decision making.

Dementia is the leading cause of death among Australian women, yet prevention strategies continue to rely largely on approaches developed from mixed-sex populations that may overlook female-specific determinants of brain health. Increasing evidence suggests that reproductive history, the menopausal transition, cardiovascular changes, sleep disturbance, psychosocial stressors, and social factors influence women's dementia risk across the life course. Despite this, these factors remain poorly integrated into dementia prevention research, risk communication, and public health practice.
WISDOM argues that dementia prevention should be viewed as a women's health equity issue. Rather than applying a one-size-fits-all approach to healthy ageing, prevention strategies must recognise the biological, social, and lived experiences that shape women's health trajectories from midlife onwards.
This presentation introduces a new public health approach that combines epidemiology, consumer partnership, and translation science to develop more relevant and actionable prevention strategies for women aged 45+ years. Through longitudinal cohort analyses and co-design with women from diverse backgrounds, WISDOM seeks to improve how dementia risk is identified, communicated, and addressed. A key output is the co-designed WISDOM Women's Brain Health Toolkit, which will provide accessible, evidence-based information and personalised risk communication to support informed health decisions during midlife.
While dementia is the initial focus, the broader message is that women's healthy ageing requires a sex-specific lens. The principles underpinning WISDOM have relevance beyond dementia, offering a model for addressing inequities in the prevention of cardiovascular disease, frailty, multimorbidity, and other chronic conditions that disproportionately affect women in later life.

Australia is overdue for a National Social Connection Strategy. Social disconnection, which includes loneliness, social isolation and poor-quality relationships, contributes to an estimated 871,000 deaths globally each year, comparable in magnitude to established behavioural risks such as smoking and physical inactivity. Despite international momentum, including the WHO Commission on Social Connection, Australia has no national strategy, governance mechanism, or population-level surveillance for social disconnection.
This presentation outlines a pathway forward, drawing on two complementary bodies of work. First, a policy analysis identifying the levers available across local, state and federal governments to strengthen opportunities for connection, from neighbourhood design and community infrastructure, to transport policy, to national surveillance and research funding. Second, a census of Council Plans from all 79 Victorian local government areas, examining how social connection is framed and operationalised against a social-ecological framework.
Preliminary findings show that proposed actions clustered disproportionately at the individual and interpersonal levels, with community and policy/system-level interventions under-represented. Furthermore, coverage varied across metropolitan, regional and rural LGAs, with other place-based factors being investigated.
Local government, however, cannot address social disconnection alone. Coordinated multi-level action must be anchored by a National Strategy that embeds social connection within existing planning, transport, preventive health and research frameworks. Concrete priorities include embedding social connection within Australia's National Preventive Health Strategy, integrating validated measures into national surveys, and establishing targeted research funding for structural interventions. Reframing social disconnection as a structural rather than individual challenge is an investment in both population health and social cohesion.

Background
South Asian migrants experience disproportionately high rates of cardiometabolic disease, yet the effectiveness of nutrition-focused interventions for this population remains unclear. This systematic review synthesises evidence on culturally tailored and standard nutrition interventions to identify effective strategies for reducing cardiometabolic risk in South Asian adults living in high-income countries.
Methods
Conducted in accordance with PRISMA 2020 and registered with PROSPERO (CRD42025114552), this review searched MEDLINE (Ovid), Embase (Ovid), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCOhost), and Scopus (Elsevier) from inception to September 2025. Thirteen studies met the inclusion criteria, comprising seven individual randomised controlled trials, three cluster randomised controlled trials, and three pre–post intervention studies. Outcomes included weight, BMI, systolic and diastolic blood pressure, and HbA1c.
Results
Culturally tailored nutrition interventions consistently produced the most significant improvements. Community health worker-led programs achieved the most significant reductions in blood pressure. Dietitian-led and community-engaged programs resulted in moderate reductions in weight and BMI. HbA1c improvements were modest but favourable for culturally adapted interventions. In contrast, digital interventions appeared less effective when cultural tailoring and interpersonal support were limited.
Conclusion
Nutrition interventions led by community health workers, incorporating cultural relevance, bilingual delivery, and community engagement, demonstrated the greatest cardiometabolic benefits for South Asian migrants. Digital-only programs without culturally grounded or interpersonal support appeared insufficient. Integrating these culturally tailored approaches into primary care and migrant health services may strengthen prevention efforts and reduce cardiometabolic disparities in this high-risk population.

Background
To analyse the epidemiological characteristics and systemic drivers of potentially preventable dental-related emergency department (ED) presentations among children and adolescents (0–17 years) within a Southeast Queensland public health service.

Methods
A retrospective cohort study of 1,108 dental-related ED visits from May 2018 to June 2024 was conducted. Presentations were identified using administrative coding for non-traumatic dental conditions and classified as potentially preventable based on established national criteria. Data were analysed using Stata 19.5 to evaluate demographic characteristics, hospital utilisation, socioeconomic status (using SEIFA indices), triage urgency, and clinical outcomes. Multivariable logistic regression identified predictors for potentially preventable versus non-preventable presentations.

Results:
The mean age at presentation was 6.8 years, with the highest utilisation in the 4–9 year age group (37.76%). Males accounted for 51.8% of visits. Most presentations were self-referred (90.9%) and occurred outside standard public dental clinic hours (73.1%). While 80.5% of patients were discharged, a marked socioeconomic gradient was observed consistently throughout the study period. Children from the most disadvantaged areas experienced substantially higher utilisation, with inequality ratios reaching 16.6:1 for the Index of Education and Occupation. Nearly half of all visits (49.5%) involved late-stage pulp/periapical disease. Younger age (0–3 years), female sex, and greater socioeconomic disadvantage were independently associated with higher odds of potentially preventable ED presentations.

Conclusion
Paediatric dental ED utilisation is primarily driven by advanced, preventable conditions in children from disadvantaged backgrounds, often occurring when primary care is unavailable. The significant inequality ratios suggest that current service models fail to reach the most vulnerable populations. These findings highlight an urgent need for targeted preventive programmes and integrated after-hours dental pathways to reduce the sustained burden on emergency services.

Ferraz dos Santos B, et al. A 10-year retrospective study of paediatric emergency department visits for dental conditions in Montreal, Canada. 2020;30(6):741-8.
Garispe A, et al. Dental Emergencies. StatPearls. Florida: StatPearls Publishing; 2023.
Aminian et al. Association between Western Australian children’s unplanned dental presentations and the socioeconomic status of their residential area Australian Health Review 2022; 46 (2): 217-21.

Background: Prior research has shown school-based oral health preventive interventions promotes health equity. This study conducted cost-effectiveness of a targeted school-based dental check-up program compared with standard care in Victoria, Australia. Subsequently, a budget impact analysis was conducted if the intervention was implemented statewide to all preschools and state government primary schools.
Methods: Cost-effectiveness analyses were performed with a 2-year time horizon from the Victorian government payer perspective. Costs were adjusted to 2024 values in Australian dollars (AUD$). The 3 outcomes of interest were the (1) incremental cost per child who have never had a dental visit (2) incremental cost per child reached from lower socioeconomic disadvantage, and (3) incremental cost per disability-adjusted life-years averted. Uncertainty was characterized using probabilistic sensitivity analysis. Budget impact analysis considered alternative scenarios using 1-way and 2-way sensitivity analyses.
Results: The incremental cost-effectiveness ratios were dominant for all 3 outcome measures, indicating that the intervention is cost-effective. The generated incremental cost-effectiveness ratios was 2AUD$1791 (2$8639; $2787) per child who never had a first dental visit, (2) 2AUD$722 (2$3484; 2$1124) per child reached from lower socioeconomic disadvantage, and (3) 2AUD$2 989 645 (2$3 487 337; $102 049) per disability-adjusted life-years averted. The budget impact analysis showed the intervention, if implemented statewide, could cost the Victorian government $96.9 million more than the base-case scenario over 5 years but provides financial protection for an additional 121 284 children.
Conclusions: This study demonstrates evidence that a targeted school-based dental check-up is cost-effective and increases equitable access and financial protection through Victorian public oral healthcare.

Accurate, reliable, and timely laboratory services are fundamental to disease surveillance, clinical decision-making, and public health response. Medical laboratories in Cambodia have adopted ISO 15189 accreditation since 2019 to strengthen laboratory quality; however, implementation has varied across institutions, with persistent challenges in workforce capacity, coordination, financing, and sustainability. Addressing these gaps is essential to building resilient and equitable health systems. This study used a participatory implementation research approach to examine barriers and opportunities for strengthening ISO 15189 implementation in Cambodia. Evidence was generated through a national multi-stakeholder workshop in September 2024, which involved laboratory professionals, policymakers, and technical partners. Data collection included facilitated discussions, structured assessment tools, and SWOT analysis across workforce development, governance, service delivery, and financing. The study identified strengths within the national laboratory system, including strong professional commitment, technical partnerships, and growing engagement in quality improvement. However, implementation gaps were consistently reported across laboratories. Key challenges included the absence of a standardized national training pathway for laboratory quality management, weak monitoring of corrective actions following audits, fragmented coordination between partners, unclear mentorship and technical oversight roles, and insufficient financial resources to sustain quality activities. Participants identified limited funding for training, mentorship, equipment maintenance, external quality assessment participation, and accreditation activities as major barriers to sustaining ISO 15189 implementation. Based on these findings, stakeholders co-developed an implementation framework centered on four priority actions: competency-based training systems, structured mentorship and performance monitoring, strengthened governance and coordination, and sustainable financing integrated into national planning processes. These findings suggest that strengthening laboratory quality systems requires coordinated system-level action beyond accreditation alone. Locally led implementation strategies, grounded in collaboration and national ownership, can support stronger laboratory services, improved health system resilience, and more equitable public health outcomes in resource-limited settings.

Cancer Council Australia have a suite of national evidence-based policies, in which we make recommendations for national action by governments and non-government organisations. These evidence-based policies have acted as a formative tool for our advocacy work and government relations and have allowed us to achieve a number of important public health milestones through the implementation of new research findings.

This presentation will serve as a discussion and reflection on how Cancer Council has utilised our policy priorities to implement public health research and consequently, achieve meaningful preventive health gains. For example, Cancer Council Australia worked closely with lead authors of the Roadmap for Optimising Screening in Australia (ROSA) Breast project, and this informed the development of our policy priority on the need to consider implementation of risk-based breast cancer screening in our national early detection breast cancer policy. Further examples include recent changes to lower the eligibility age for bowel cancer screening, and implementation of a new targeted national lung cancer screening program, which have been incorporated into the existing national policy and used as a catalyst to develop a new early detection policy, respectively.

At Cancer Council, we work consistently to ensure that our national policies remain evidence-based, and that this work reflects and incorporates the latest research findings, as this influences our advocacy approach and policy recommendations.

Therefore, we recommend and encourage research articles to include clear policy recommendations within their studies, to help facilitate the link between policy and research, and allow for ease of implementation of research findings. Further, we would encourage collaboration from researchers with Cancer Council Australia on work that has national policy implications.

Ongoing collaboration will help to ensure timely implementation of research into practice to achieve preventive health gains with Cancer Council continuing to act as the national advocacy voice in this space.

Public health agencies should use an algorithmic visibility test before deploying AI-assisted prioritisation in prevention, outreach, surveillance or resource allocation. Predictive systems are increasingly promoted as tools for making public health more precise and efficient. However, their value depends on a prior equity question: who becomes visible to the system, and who remains missing?

This Ideas in Action presentation argues that AI models trained on routine health, service-use or administrative data may mistake recorded need for actual need. Populations with high underlying risk but weaker data visibility, including people with limited service contact, language barriers, unstable housing, low institutional trust or migration-related exclusion, may be under-prioritised because they are less legible to existing systems. The problem is not that AI is inherently inequitable, but that models can reproduce the blind spots of the systems that generate their data.

The proposal is grounded in evidence from health algorithm bias showing that apparently neutral proxies, such as healthcare cost, can produce inequitable allocation when they reflect unequal access rather than underlying illness. It also aligns with public health concerns about fairness, accountability, transparency and human rights in AI for health.

The presentation offers a practical algorithmic visibility test for public health teams. Before deployment, agencies should ask: What decision will the tool influence? Which groups may be missing, misclassified or under-recorded? Which proxy variables may encode structural inequity? Who remains accountable for final decisions? What distributional outcomes will be monitored after implementation?

The intended outcome is a shift in how public health evaluates AI: not only by accuracy or efficiency, but by whether predictive systems expand or narrow the populations seen, prioritised and protected.

There is a well-documented translation gap that exists between research and practice in preventive health, and we know that this serves as a major barrier to the implementation of effective health policy. It is estimated that 85% of health research is wasted 1, and large temporal lags exist, with an average time of 17 years for research to be translated into clinical practice2,3.

Evidence-based national policies and strategies can bridge this gap by applying research into coordinated action, however, there must be clear mechanisms for implementation and evaluation in place, as well as adequate and sustained funding, for these policies to achieve meaningful public health gains.

Cancer Council Australia’s Cancer Control Policy team undertook an internal analysis of submissions we had made to consultation on national strategies, frameworks and roadmaps related to cancer control. These submissions were reviewed to identify common themes and recurring issues, that could help inform our ongoing advocacy to strengthen national health policy.

Our results demonstrated an absence of clear monitoring and evaluation mechanisms, and a lack of clear implementation plans. Further, there were delays in several of the strategies releasing their final reports.

Cancer Council developed a suite of recommendations to ensure that research translates into improved health outcomes, and that national policies are able to achieve the goals and priority areas that they have determined.

Our findings from this internal analysis, and our suite of recommendations are being documented in a policy framework document, which we will use to inform our recommendations for future policy consultations, and can be shared with other relevant public health organisations to ensure that we have consistent and aligned messaging in our responses. Cancer Council are working to publish the findings of this work in a relevant Australian public health journal, to further amplify our advocacy work in this space.

References
1. Chalmers I, Glasziou P. Avoidable waste in the production and reporting of research evidence. The Lancet. 2009;374(9683):86–9.
2. Balas EA, Boren SA. Managing Clinical Knowledge for Health Care Improvement. Yearb Med Inform. 2000(1):65–70.
3. Morris ZS, Wooding S, Grant J. The answer is 17 years, what is the question: understanding time lags in translational research. J R Soc Med. 2011;104(12):510–20.