Resting heart rate has been shown to be inversely associated with risk of all-cause mortality and cardiovascular disease, including incident heart failure.1–3 This makes it a potential clinical marker of cardiovascular health, which can be feasibly assessed in epidemiological studies.4 Moreover, with the increasing availability of wearable devices able to provide real-time estimates of heart rate, and evidence supporting the use of wearable devices in cardiovascular disease prevention, diagnosis, and management,5 understanding resting heart rate and its determinants may provide insights into the pathway to prevent cardiovascular risk in young- to mid-age adults.
Physical activity is an important modifiable factor associated with reduced risks of all-cause and cardiovascular disease mortality as well as a reduction in health care costs.6,7 Improved cardiorespiratory fitness, as a result of an active lifestyle, is one way in which physical activity partially affects cardiovascular health. This is possibly through a reduction in cardiac oxygen consumption primarily due to a lower resting heart rate.8 Laboratory-based studies have shown that physical activity, particularly at higher intensities, can lead to improved cardiorespiratory fitness,9,10 which is associated with lower cardiovascular disease mortality11 as well as positive clinical markers of health, such as lower levels of inflammation,12 lower cerebrovascular resistance, and elevated cerebrovascular reactivity at rest.13 Hence, it would to be expected that high levels of physical activity throughout adulthood are associated with lower resting heart rates before the transition to late adulthood. However, there is limited evidence on the strength of the association between daily life physical activity across the life span and cardiovascular health. Furthermore, little is known about the extent to which physical activity accumulated over adulthood contributes to long-term health outcomes, especially among individuals whose physical activity pattern changes across the lifespan.14
Most epidemiological evidence of the benefits of physical activity for cardiovascular health relied on physical activity measured at one time point.7,14 This traditional approach is problematic, particularly for understanding relationships between physical activity and development of cardiovascular diseases in women, as major life events, such as pregnancy, may lead to long periods of low physical activity.15–18 The current state of knowledge still does not allow us to comprehend the extent to which the physical activity accumulated in specific periods of the lifespan may trigger health benefits later in life or whether the benefits of high levels of physical activity accumulated during a life stage are “washed out” when life constraints lead to periods of inactivity. Data from the HUNT Study have shown that adults who remained physically inactive and those who decreased their physical activity had higher risk of all-cause and cardiovascular disease mortality than those who were constantly active throughout the lifespan.19 Similarly, Saint-Maurice et al20 have shown that long-term participation in physical activity and becoming physically active later in adulthood may also provide comparable health benefits. However, in both studies, individuals who were active early in adulthood but decreased their levels of physical activity by mid to older ages appeared to have little cardiovascular disease-related mortality protection.19,20
The importance of timing of physical activity across the life course for cardiovascular health is to be determined.14 To date, few studies have explored the associations between changes in physical activity across the lifespan and all-cause and cause-specific mortality. As the risk of the onset of chronic diseases increases markedly from young to older adulthood,21 the role accumulation and timing of physical activity in reducing the risk of major cardiovascular conditions should be investigated further. Therefore, the overall aim of this study was to investigate the association between physical activity accumulated over 18 years (from early to mid-adulthood) and resting heart rate among Australian women in their mid-40s.
Methods
Study Population and Sample
We used data from the Menarche to Premenopause (M-PreM) study, which was conducted in 2019 from a sample of women born in 1973–1978 who were participants in the Australian Longitudinal Study on Women’s Health (ALSWH).22 In brief, ALSWH randomly recruited women born in 1973–1978 who were included in the database of Medicare (Australia’s universal health insurance scheme) in 1996. Women who accepted participation were later invited to respond to surveys every 3 years from 2000 (age 22–27 y) to 2018 (age 40–45 y). These surveys collected physical activity information among other sociodemographic and health characteristics of participants. M-PreM was designed to collect clinical data at age 41–46 years from a sample of the women in the 1973–1978 cohort who were not pregnant or had not been diagnosed with a reproductive cancer at the time of invitation in 2019. Although the M-PreM study recruited 1327 participants, due to the SARS-CoV-2 (COVID-19) outbreak in Australia, only 499 participants completed the clinical assessment. For this study, 479 women who had data for resting heart rate and physical activity information from at least 4 surveys (out of 7 possible) were included in the analyses. Further details about ALSWH and M-PreM studies have been published elsewhere.22,23
Resting Heart Rate
Resting heart rate was assessed using an automated blood pressure monitor when participants were 41–46 years old. Women rested in a seated position for 5 minutes before they had their heart rate measured. Three measurements of heart rate were conducted interspersed by 1- to 2-minute breaks. For analysis, only the second and third measurements were averaged, as recommended by the World Health Organization protocol.24
Physical Activity
Physical activity was assessed in each survey using a modified version of the Active Australia Survey, which is used for physical activity surveillance in Australia and has acceptable levels of reliability and validity.25 Total duration of walking (for exercise/recreation or to get to and from places) as well as moderate-intensity and vigorous physical activities in the last week were reported. Metabolic equivalents of task (METs), where 1 MET is the energy expected at rest, were attributed to each activity. Weekly volume of physical activity for each participant was calculated as the sum of minutes spent walking and in moderate physical activity (weighted by a MET value of 3.33) and the duration of vigorous physical activity (weighted by a MET value of 6.66). For reference, a volume of 500 to 1000 MET-minutes per week approximates the recommended levels of 150 to 300 minutes per week of moderate-intensity or 75 to 150 minutes per week of vigorous-intensity physical activity, or an equivalent combination of both.7,26
Covariates
Sociodemographic and health-related covariates were assessed in each survey using standardized questionnaires (available at https://alswh.org.au/for-data-users/data-documentation/surveys/). For this study, the following data collected at age 40–45 years were used as potential confounders for the associations between physical activity and resting heart rate: age (in years), educational attainment (highest grade of school completed), smoking status (never, former, or current smoker), alcohol consumption (low-risk drinker, nondrinker, rarely drinks, and risky/high-risk drinker), number of children (0, 1, or 2+), and body mass index (calculated based on self-reported weight and height).
Statistical Analysis
Initially, a cumulative physical activity score was created as the sum of physical activity levels across all the surveys divided by the number of surveys for which each participant had data available. Participants were classified into tertiles of the cumulative scores. The sample was described by tertiles of cumulative physical activity using means and SD, medians and interquartile ranges, and proportions. Analysis of variance, Kolmogorov–Smirnov, and chi-squared tests were used to assess the association between participants’ characteristics and tertiles of cumulative physical activity. Two different approaches were used to examine the relationship between physical activity throughout adulthood and resting heart rate.
First, crude and adjusted linear regression models were used to investigate the association between accumulation of physical activity and resting heart rate. Predictive margins for resting heart rate at age 41–46 years and respective 95% confidence intervals (CIs) were estimated based on increments of 100 MET-minutes per week in the cumulative physical activity score. To account for the potential nonlinearity of the association between cumulative physical activity and resting heart rate, the regression models included quadratic terms for cumulative physical activity. The predictive estimates were limited to cumulative physical activity levels between the 5th and 95th percentiles of the physical activity distribution to limit estimates to realistic values of physical activity. The predictive margins were estimated after adjusting for age, education, smoking, alcohol consumption, number of children, and body mass index. Interaction terms between cumulative physical activity and physical activity at age 40–45 years were also tested in the models to account for different associations between physical activity accumulated across adulthood and the current level of physical activity of each participant. However, as the analyses did not show any interactions between the accumulation of physical activity from surveys 2 to 7 and physical activity at survey 8 (P > .6), the final models did not include an interaction term.
Second, we explored the associations of timing and changes in physical activity with resting heart rate. For this, we calculated the average physical activity from survey 2 (age 22–27 y) to survey 4 (age 28–33 y) and from survey 6 (age 34–39 y) to survey 8 (age 40–45 y). Participants were then categorized into 3 groups (low, moderate, or high physical activity) based on tertiles of the physical activity distribution in each period. Subsequently, participants were classified into 9 groups based on their physical activity categories in each age period (eg, low-low; low-high). Crude and adjusted linear regression models were used to investigate the association of (1) average physical activity from age 22–27 years to age 28–33 years (hereafter referred to as physical activity from 22 to 33 y), (2) average physical activity from age 34–39 years to age 40–45 years (hereafter referred to as physical activity from 34 to 45 y), and (3) the 9 profiles of physical activity from age 22–33 years to 34–45 years with resting heart rate at age 41–46 years. Due to multiple comparisons, the interpretation of findings was based on the size of differences and overlap of CIs. All analyses were performed using Stata (version 17.0).
Results
Sociodemographic characteristics of the sample are presented in Table 1. Overall, most women had at least a university degree, never smoked, and were low-risk drinkers. The average level of physical activity from age 22–27 years to age 40–45 years was 1083 MET-minutes per week (SD: 779). Overall, women with higher education and lower body mass index at age 40–45 years were more likely to be in the top tertile of cumulative physical activity scores (Table 1). The distribution of resting heart rate at age 41–46 years is displayed in Figure 1. The average resting heart rate was 75 beats per minute (bpm; SD: 11). One quarter of participants had a resting heart rate above 82 bpm; 10% had a resting heart had above 89 bpm.
Sociodemographic and Health Characteristics of Participants With Resting Heart Rate and Physical Activity Measurement (N = 479)
| Variables collected at survey 8 (age 40–45 y) | Cumulative physical activity (tertiles) | ||||
|---|---|---|---|---|---|
| All N = 479 | First n = 161 | Second n = 159 | Third n = 159 | P | |
| Categorical variables, n (%) | |||||
| Highest qualification completed | <.001b | ||||
| Certificate, diploma, high school | 118 (24.6) | 58 (36.0) | 37 (23.3) | 23 (14.5) | |
| University degree | 185 (38.5) | 55 (34.2) | 64 (40.2) | 66 (41.5) | |
| Higher university degree | 177 (36.9) | 48 (29.8) | 58 (36.5) | 70 (44.0) | |
| Smoke status | .306b | ||||
| Never | 332 (69.3) | 105 (65.2) | 114 (71.7) | 113 (71.1) | |
| Former | 119 (24.8) | 44 (27.3) | 34 (21.4) | 41 (25.8) | |
| Current | 28 (5.9) | 12 (7.5) | 11 (6.9) | 5 (3.1) | |
| Alcohol consumption | .540b | ||||
| Low-risk drinker | 329 (68.7) | 107 (66.5) | 111 (69.8) | 111 (69.8) | |
| Nondrinker | 37 (7.7) | 12 (7.5) | 12 (7.6) | 13 (8.2) | |
| Rarely drinks | 85 (17.8) | 36 (22.3) | 25 (15.7) | 24 (15.1) | |
| Risky drinker/high-risk drinker | 28 (5.8) | 6 (3.7) | 11 (6.9) | 11 (6.9) | |
| Number of children | .007b | ||||
| None | 97 (20.2) | 22 (13.4) | 28 (17.6) | 47 (29.6) | |
| 1 | 55 (11.5) | 18 (11.2) | 21 (13.2) | 16 (10.1) | |
| 2+ | 327 (68.3) | 121 (75.2) | 110 (69.2) | 96 (60.3) | |
| Continuous variables | |||||
| Age, y, mean (SD) | 42.3 (1.5) | 42.3 (1.5) | 42.2 (1.5) | 42.2 (1.5) | .676c |
| Body mass index, kg/m2, mean (SD) | 26.7 (6.2) | 27.9 (6.6) | 26.6 (6.6) | 25.7 (5.1) | .008c |
| Physical activity at age 22–27 y,a MET-min/wk | 799 (366–1499) | 400 (183–632) | 866 (491–1398) | 1632 (833–2447) | <.001d |
| Physical activity at age 25–30 y,a MET-min/wk | 799 (300–1482) | 333 (133–699) | 899 (466–1399) | 1508 (874–2398) | <.001d |
| Physical activity at age 28–33 y,a MET-min/wk | 799 (366–1398) | 400 (158–599) | 799 (400–1382) | 1399 (799–2398) | <.001d |
| Physical activity at age 31–36 y,a MET-min/wk | 699 (266–1232) | 300 (58–574) | 799 (400–1199) | 1198 (699–1998) | <.001d |
| Physical activity at age 34–39 y,a MET-min/wk | 599 (200–1199) | 275 (87–599) | 633 (333–999) | 1232 (599–2173) | <.001d |
| Physical activity at age 37–42 y,a MET-min/wk | 699 (246–1573) | 200 (67–500) | 699 (400–1132) | 1798 (899–2797) | <.001d |
| Physical activity at age 40–45 y,a MET-min/wk | 799 (300–1598) | 300 (50–599) | 799 (400–1369) | 1798 (999–2797) | <.001d |
| Average physical activity across adulthood,a MET-min/wk | 901 (555–1363) | 442 (289–556) | 909 (775–1066) | 1707 (1363–2152) | <.001d |
Abbreviation: MET, metabolic equivalents of task.
aValues reported as median (25th–75th centile). bChi-square test. cAnalysis of variance. dKolmogorov–Smirnov test.
—Distribution of resting heart rate of women at age 41–46 years. (N = 479). bpm indicates beats per minute.
Citation: Journal of Physical Activity and Health 20, 9; 10.1123/jpah.2023-0082
Cumulative Physical Activity and Resting Heart Rate
An inverse, nonlinear dose–response association between physical activity accumulated over 18 years and resting heart rate at age 41–46 years was observed. Among women with an average physical activity over 18 years of approximately 1300 to 1400 MET-minutes per week, resting heart rate at age 41–46 years was lower than the average resting heart rate in the sample (75 bpm; Figure 2). Overall, the inverse association between physical activity and resting heart rate was linear to levels of physical activity close to 2000 to 2600 MET-minutes per week (mean resting heart rate: 71 bpm). Physical activity levels higher than 2600 to 3000 MET-minutes per week were not associated with additional benefits for resting heart rate. Compared with women who were among the 33% least active group (average 414 MET-min/wk), those in the highest tertile of physical activity (average 1929 MET-min/wk) had an average resting heart rate that was 4 bpm lower (Table 2). Overall, women with a cumulative score lower than 500 MET-minutes per week had a resting heart rate of 78 bpm (95% CI, 76 to 80), whereas those with a cumulative score of 2600 to 3000 MET-minutes per week had an average resting heart rate of 72 bpm (95% CI, 70 to 74). In addition, we tested the associations between the number of surveys in which women met the physical activity guidelines and resting heart rate at ages 41–46 years for the 290 participants who had physical activity data for all surveys. The results showed a similar trend, with the lowest resting heart rate observed among the participants who met the physical activity guidelines in all surveys (data not shown).
—Average physical activity from age 22–27 years to age 40–45 years and its association with resting heart rate at age 41–46 years. (N = 475). Adjusted for age, education, smoking, alcohol, number of children, and body mass index. Horizontal dashed line represents sample average of resting heart rate. bpm indicates beats per minute; CI, confidence interval; MET, metabolic equivalents of task.
Citation: Journal of Physical Activity and Health 20, 9; 10.1123/jpah.2023-0082
Association Between Physical Activity Across Adulthood and Resting Heart Rate at Age 41–46 Years (N = 475)
| Physical activity variables (tertiles) | Unadjusted | Adjusteda |
|---|---|---|
| β (95% CI) | β (95% CI) | |
| Average physical activity from age 22–45 yb | ||
| First | Reference | Reference |
| Second | −2.47 (−4.72 to −0.22) | −1.99 (−4.26 to 0.28) |
| Third | −5.18 (−7.43 to −2.93) | −4.42 (−6.77 to −2.07) |
| Average physical activity from age 22–33 yc | ||
| First | Reference | Reference |
| Second | −3.18 (−5.45 to −0.92) | −2.70 (−4.98 to −0.42) |
| Third | −4.05 (−6.32 to −1.79) | −3.51 (−5.82 to −1.20) |
| Average physical activity from age 34–45 yd | ||
| First | Reference | Reference |
| Second | −3.20 (−5.46 to −0.94) | −2.68 (−4.96 to −0.40) |
| Third | −4.40 (−6.65 to −2.15) | −3.52 (−5.85 to −1.19) |
Abbreviation: CI, confidence interval.
aAdjusted for age, education, smoking, alcohol, number of children, and body mass index. bAverage physical activity from survey 2 (age 22–27 y) to survey 8 (age 40–45 y). cAverage physical activity from survey 2 (age 22–27 y) to survey 4 (age 28–33 y). dAverage physical activity from survey 6 (age 34–39 y) to survey 8 (age 40–45 y).
Timing of Physical Activity and Resting Heart Rate
Associations of physical activity from age 22–33 years and age 34–45 years with resting heart rate are presented in Table 2, and the association between the profiles of physical activity over 18 years with resting heart rate is presented in Figure 3. Those in the highest tertiles of physical activity during each age period had resting heart rates, on average, 4 bpm lower than those in the lowest tertiles (Table 2). Compared with women who were consistently in the lowest tertile of physical activity, those who were moderately active at least once had lower resting heart rates. Women who transitioned from low to high physical activity (adjusted β: −3.59; 95% CI, −8.00 to 0.81) and those who transitioned from high to low physical activity (adjusted β: −3.76; 95% CI, −7.84 to 0.32) between ages 22–33 years and 34–45 years tended to have slightly lower resting heart rate than the reference group (low-low). However, the differences observed in both cases included the reference value within the 95% CI. Women in the highest tertile of physical activity at both age 22–33 years and 34–45 years had the lowest resting heart rate; on average, their resting heart rate was 8 bpm lower (95% CI, −11.42 to −4.69) than the resting heart rate of women in the low-low group. Sensitivity analyses, which excluded body mass index from the models (as it could potentially mediate the relationship), yielded beta coefficients similar to those presented in Figure 3 but with narrower CIs.
—Association between profiles of physical activity over 18 years and resting heart rate. Low, moderate, and high are, respectively, the first, second, and third tertiles of physical activity in each time point; analysis was adjusted for age, education, smoking, alcohol, number of children, and body mass index. bpm indicates beats per minute; CI, confidence interval.
Citation: Journal of Physical Activity and Health 20, 9; 10.1123/jpah.2023-0082
Discussion
Findings from this cohort of Australian women showed that greater accumulation of physical activity over 18 years across adulthood was associated with lower resting heart rate at age 41–46 years. Overall, accumulation of physical activity was associated with lower resting heart rate irrespective of the age when physical activity was accumulated. Compared with the group that was least active at age 22–33 years and 34–45 years, those who had at least moderate levels of physical activity at any period across adulthood (the mid-20s or mid-30s) had lower resting heart rates and were likely to have better cardiovascular health. Our findings from a population-based cohort of women with almost 20 years of data collected over multiple waves provide unique insights into the understanding of the potential benefits of physical activity accumulated across adulthood for cardiovascular health of women before the transition to menopause.
We observed an inverse association between physical activity over 18 years and resting heart rate at age 41–46 years. Women who accumulated an average of approximately 1300 to 1400 MET-minutes per week had lower resting heart rates than the average in the sample. Women in the highest tertile of physical activity in the age periods 22–33 years and 34–45 years had resting heart rates of 8 bpm lower than those consistently in the lowest tertile; those with a cumulative score of 2600 to 3000 MET-minutes per week had an average resting heart rate of 6 bpm lower than women with a cumulative physical activity score of 500 MET-minutes per week. Although the magnitude of the associations between physical activity and resting heart rate was small, and perhaps not clinically important at the individual level at the age of 41–46 years, previous studies have suggested that even an increase in resting heart rate of 1 bpm was associated with a 1.1% increase in all-cause mortality in adults.27 Moreover, data from over 25,000 women participants in the HUNT study (Norway) have shown that each increment of 10 bpm was associated with an 18% increased risk of mortality from ischemic heart disease in women <70 years of age and that the risk associated with a high resting heart rate may be substantially reduced among women who were physically active.28
Results from our study suggest that women who are at least moderately active in one age period may experience cardiovascular health benefits. We observed that women who transitioned from low to high physical activity, and those who transitioned from high to low physical activity, between the ages of 22–33 years and 34–45 years tended to have slightly lower resting heart rate than those with low physical activity in both periods. Although we could not directly compare findings from our study to other studies that used a similar approach, Nagata et al analyzed 30 years of data from the Coronary Artery Risk Development in Young Adults study and reported similar findings to ours. In their study, it was suggested that physical activity from young adulthood to middle age was associated with lower incidence of premature cardiovascular events, especially stroke and heart failure.29 In contrast, using data of adults from the Copenhagen City Heart Study, Schnohr et al30 found that individuals who maintained or increased their physical activity levels over a span of 33 years had a lower risk of both coronary heart disease and all-cause mortality than those who maintained low levels of physical activity during that period. However, they did not observe any associations between decreased physical activity and a lower risk of these conditions. Other studies have also suggested that individuals who were active in their early adulthood but decreased their levels of physical activity as they entered mid to older ages seemed to have little or no protection against cardiovascular disease-related mortality.19,20
The acute and chronic effects of physical activity on the cardiovascular system can partially explain the findings of our study. These include improvements in cardiorespiratory fitness, acute blood pressure, and cardiac stroke volume.9,31 For example, regular physical activity increases cardiac output and function, which results in an increase in stroke volume, increased efficiency of heart muscle contraction, and improved blood flow, hence leading to a decrease in heart rate that can persist even during periods of rest.31 Moreover, physical activity increases the concentration of stress hormones (eg, epinephrine and norepinephrine), which are involved in cardiorespiratory adjustments and can contribute to a decrease in resting heart rate.32 However, the physiological mechanisms underlying the relationships between cumulative physical activity and resting heart rate observed in our study, especially among women who were highly active in their 20s and became inactive in their 30s to 40, still need to be fully understood and require further investigations.
Limitations of this study need to be acknowledged. Due to the small sample size, the categorization of physical activity was relatively crude, which limited the investigation of the minimal and optimal amounts of physical activity associated with resting heart rate. Self-reported physical activity is subject to misclassification due to recall and social desirability bias.33 However, 7 repeated measures over 18 years are likely to reduce misclassification.34 Resting heart rate at age 22–27 years was not accessed and, therefore, not included in the analytical model. Thus, although unlikely, reverse causation cannot be ruled out of these findings. Residual confounding due to unmeasured confounders, such as diet and stress levels, might partially explain the associations observed in the study. Finally, although our findings suggest that accumulation of physical activity is associated with resting heart rate, the cumulative physical activity score used in our study was calculated as an average of repeated surveys, which reduces random measurement error and minimizes within-participant variation over time34 and, therefore, might explain the observed associations. Hence, the extent to which the associations were a result of accumulation of physical activity instead of a consequence of the increase in precision of measurement of the exposure variable that occurs with repeated measures should be considered in the interpretation of these our findings. Nonetheless, this study has several strengths. We analyzed data from a large population-based prospective study with 18 years of data and repeated measures of physical activity using the same instrument. This enabled the investigation of a conceptual model that addressed aspects of the individual’s life history related to physical activity.
To date, few studies have used life course epidemiology models, such as the accumulation model, to explore the extent to which growing a “physical activity bank savings” throughout the lifespan is important for preventing diseases.14 Advancing knowledge about the potential effects of accumulating physical activity is important, particularly for women as pregnancy and childbearing drastically impact on levels of physical activity.15,17,35 As our findings suggest that accumulation of physical activity might provide benefits for cardiovascular health irrespective of timing for women, tailored public health messages that take into account the amount of physical activity accumulated across the reproductive ages might be particularly important for women who are likely to decrease physical activity due to pregnancy.15
In conclusion, this study represents an important contribution to understanding the role of physical activity across the lifespan on maintaining heart-related health in women. Physical activity across adulthood is associated with lower resting heart rate in mid adulthood. In addition, accumulation of physical activity, irrespective of timing, seems to provide benefits for the cardiovascular health of women before the transition to menopause. Based on the findings of our study, future public health messages could highlight the benefits of accumulating physical activity at different stages of a woman’s life as an important factor in maintaining cardiovascular health before the transition to menopause.
Acknowledgments
The authors would like to acknowledge the Australian Government’s Department of Health and Aged Care for funding the ALSWH. The authors would also like to thank the women who participated in ALSWH and the M-PreM study. Author Contributions: Mielke and Mishra conceived of the study. Mielke performed the analyses, participated in the study design, and reviewed the literature. Doust, Chan, and Mishra participated in the study design and reviewed the literature. All authors contributed to multiple revisions of the article. All authors read and approved the final manuscript. Funding: Mielke is supported by a National Health and Medical Research Council Investigator Grant (APP2008702). The M-PreM Study is supported by the National Health and Medical Research Council Project Grant (APP1129592). Mishra is supported by a National Health and Medical Research Council Leadership Fellow (APP2009577). Ethics Approval: This study involves human participants and was approved by the Metro South Health and Health Services Human Research Ethics Committee (reference number: HREC/2019/QMS/52052) and ratified by the University of Newcastle and the University of Queensland Human Research Ethics Committees. All participants provided informed consent by completing an electronic or paper participant consent form. Data Availability Statement: Data are available upon reasonable request. Access to the M-PreM dataset requires approval from the ALSWH Data Access Committee. More information can be found at the ALSWH website: https://alswh.org.au/for-data-users/.
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