Eastern Health - Health PromotionIntegrated Health Promotion Plan 2017 – 2021

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Introduction

Health Promotion is an important part of Eastern Health Community Health, complementing the delivery of primary health care services to the communities of the Yarra Valley. As a health sector discipline, Health Promotion is uniquely placed as our focus is on primary prevention. Primary prevention has been described as a “long term agenda” (Victorian Government, Free from Violence Strategy, 2017). It is about changing the conditions which enable illness or the conditions for injury to develop in the first place. It involves working with the complexity of open systems, where multiple factors with a diversity of external interactions and relationships create the necessary conditions for illness and injury.

Health promotion represents a comprehensive social and political process, it not only embraces actions directed at strengthening the skills and capabilities of individuals, but also action directed towards changing social, environmental and economic conditions so as to alleviate their impact on public and individual health. Health promotion is the process of enabling people to increase control over the determinants of health and thereby improve their health. Participation is essential to sustain health promotion action (World Health Organization, 1998)

The Victorian Public health and wellbeing plan (VPHWP) 2015 – 2019 (State of Victoria, 2015) outlines the foundation for all public health promotion interventions:

Estimates suggest that around one-third of the total burden of disease and injury is potentially avoidable, whether through preventing problems before they occur or finding problems early and treating them (Jardine et al. 2010)….WHO has estimated that up to 80 per cent of all heart disease, stroke anddiabetes cases, and up to 40 per cent of all cancers, are potentially avoidable through preventive interventions (World Health Organization 2005). Consistent with this, in 2003, 32 per cent of the total burden of disease in Australia was due to the joint effect of 14 modifiable risk factors (Begg et al. 2007).

The Ottawa Charter (1986) outlines five priority action areas for health promotion (World Health Organisation, 2017):

Build healthy public policy Create supportive environments for health Strengthen community action for health Develop personal skills Re-orient health services

In 2016 and 2017 several new policy frameworks were introduced that have created clarity and purpose around the strategic priorities for health and wellbeing for the state. In 2017 the Department of Health and Human Services has directed that all health promotion plans are to align with the priorities of the VPHWP 2015 – 2019 and the relevant Local Government Municipal Health and Wellbeing Plan. This line of sight aims to ensure strategic investment by the State Government in primary prevention activities and support the conditions for collective impact on population health in our localities. The Victorian public health and wellbeing plan (State of Victoria, 2015) has six key priority areas:

healthier eating and active living tobacco-free living reducing harmful alcohol and drug use improving mental health

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Eastern Health - Health Promotion would like to acknowledge that we are working on the traditional lands of the Wurundjeri people and that we respect the Aboriginal and Torres Strait Islander community that make these lands their home and we acknowledge their elders, past, present and emerging.

preventing violence and injury improving sexual and reproductive health.

The Victorian public health and wellbeing outcomes framework (State of Victoria, 2016) describes a suite of measures and indicators that will be used to track progress. Interim indicators will be released as they are developed, for example, the Family Violence Index (Victorian Government, 2015).

Eastern Health Strategic Plan 2017- 2022

Eastern Health is a large and complex health service, delivering a wide range of secondary and tertiary health services across Melbourne’s Eastern Metropolitan Region. Our primary catchment comprises almost 774,000 individuals with a further 324,000 people residing within our secondary catchment area. The Eastern Health Vision is for Great Care, Everywhere, Every Time. Our mission is that “Together we care, learn, discover and innovate and that “In partnership with each other, our consumers, other health care providers and an array of other organisations we care for the community”.

The 2017 – 2021 Integrated Health Promotion Plan intends to work across risk factors within settings that have already shown a degree of readiness, response or activation as a result of the investment of previous years of intervention. The recently launched National Strategic Framework for Chronic Conditions has a new approach that “recognises that there are often similar underlying principles for the prevention and management of many chronic conditions….this framework moves away from a disease-specific focus and better considers shared health determinants, risk factors and multi-morbidities across a broad range of chronic conditions” (Australian Health Ministers’ Advisory Council, 2017). Although our strategies may focus on risk factors or priority areas in isolation, in reality they often occur together (Australian Health Ministers’ Advisory Council, 2017). Health Promotion aims to take an “upstream” approach – that is, preventing illness or disease before it occurs in order to reduce the number of episodes of care at Eastern Health that contribute to preventable and avoidable hospital admissions.

The Health Promotion team is part of the Child and Family Team within Community Health at Healesville Hospital & Yarra Valley Health. The development of our four year Integrated Health Promotion Planning involved:

Reviewing local and regional health data. Aligning our focus with the state priorities in VPHWP, the Victorian public health and

wellbeing outcomes framework and the Yarra Ranges Council Municipal Health and Wellbeing Plan.

Consultation with local stakeholders including Yarra Ranges Council and local provider and community networks.

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Figure 1: Eastern Health Strategic Plan 2017 - 2022

Liaising internally with Eastern Health stakeholders to determine organisational priorities.

Reviewing and analysing the evidence of interventions for each priority area. Examining our local community context, existing initiatives and the readiness of

settings for further advocacy or intervention. Examining our own practice capability to identify strengths and potential for

collaborative impact.

Our communities – Priorities for Health Promotion in the Yarra Valley Catchment

Under the direction of the Department of Health and Human Services during 2016 Eastern Health Health Promotion initiated a shared planning process for prevention initiatives with Yarra Ranges Council. Yarra Ranges Council has reviewed and developed its new Council Municipal Health and Wellbeing Plan (2017 – 2021). Extensive consultation regarding community vision, values and priorities was conducted by Yarra Ranges Council in 2015 and 2016. This work was used to extrapolate community priorities for health and wellbeing and formed the basis of the selection of the 13 Goals in the new Health and Wellbeing Plan:

Connected and healthy communities

Goal 1: People are able to access, prepare and eat nutritious foodsGoal 2: People enjoy good mental health throughout their livesGoal 3: People who drink alcohol do so in moderation and safetyGoal 4: People participate in learning and education across life-stagesGoal 5: People are engaged in local decision making and leadership

Resilient and liveable communities

Goal 6: People are physically activeGoal 7: People have access to active transport modes such as walking, cycling and public transport.Goal 8: People are able to contribute to and participate in their local economy.Goal 9: People have access to vibrant arts and heritage experiences that connect communities.Goal 10: People enjoy safe, sustainable natural and built environments.Goal 11: People have suitable, affordable and stable housing.Goal 12: Every child and young person can thrive and reach their potential.Goal 13: Older people enjoy active and healthy lives.

Equitable and inclusive communities

Goal 14: People belong to and participate equally in inclusive communities.Goal 15: People can access appropriate health services.Goal 16: Women and children live free from abuse and violence through a culture of gender equity and respect.Goal 17: Indigenous residents –

live free from discrimination and racism, connected to their culture & identity.

access culturally safe services in community controlled organisations are supported to have healthy pregnancies and thrive in early

childhood

In reviewing the local health profile, the following excerpt from the council summary (Health and Wellbeing in the Yarra Ranges, Yarra Ranges Council, 2017) describes how the Yarra Ranges population compares to Victorian averages for a range of measures related to the main health risk factors for developing chronic disease (healthy eating, physical activity, alcohol use and mental health):

Despite our beautiful natural environments, the high levels of community connection, and the Yarra Ranges’ strong potential for economic renewal and growth, the community compares poorly on several health benchmarks, physical and mental. Of greatest concern are statistics on diabetes, obesity, dental health, alcohol consumption and levels of psychological distress.Yarra Ranges has worse than average survey results on these main health risk factors:

- Only 44% of residents meet fruit consumption guidelines: Victorian average is 48%.

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- 82% of residents eat takeaway foods about once a week: Victorian average is 71%.

- 33% of residents are overweight: Victorian average is 31%.- Residents are more likely to spend a lot of time sitting on weekends. - Residents are unlikely to cycle or walk more than 10 minutes for transport.- 45% of residents are at increased risk of alcohol-related harm on any single

occasion: Victorian average is 42.5%.- 20% of residents have high or very high levels of psychological distress:

Victorian average 12.6%.

Council research reveals that individual choices and the environments we live in make a large contribution to these outcomes - particularly through poor nutrition and insufficient exercise - although the impacts of inequity and disadvantage also warrant serious consideration.

The prevention of violence against women is also a priority issue for the Yarra Valley communities. Statistically, the Yarra Ranges has the 2nd highest rate of family violence across the local government areas of the eastern region (Connecting Young People, Yarra Ranges Council, 2017). In terms of health, young people in the Yarra Ranges have high rates of anxiety and depressed mood and higher than average rates of hospitalisation for psychological distress when compared to the state average (Connecting Young People, Yarra Ranges Council, 2017). The following table show how the Yarra Ranges population compares

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to the Victorian state average for a range of risk factors:

Red = Worse than the state averageGreen = Better than the state average

The population trends for overweight and obesity, cardiovascular disease, diabetes and asthma point to an expected rise in hospital admissions from the Yarra Valley catchment communities to the major hospitals of Eastern Health at Maroondah, the Angliss and Box Hill (Eastern Health Clinical Services Plan, 2012). It is vital that we work to support individuals and communities to adopt approaches that reduce the risk of developing chronic diseases and prevents avoidable future hospital admissions. The isolation, socio-economic status and conditions of entrenched inter-generational disadvantage point to an urgent need for health promotion interventions that can build individual, family and community capacity to support environments for wellbeing. Eastern Health Health Promotion is well placed to contribute to

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this change through expertise in advocacy, program development, health literacy and community engagement.

Our Health Promotion Principles

The Health Promotion team has reviewed its practice during 2016 and particularly reflected on the approach, values and skills required to enhance our capability. The following principles are considered fundamental to the delivery of Health Promotion practice in the Yarra Valley for the next four years:

Equitable and inclusive“Health inequities are differences in health status between population groups that are socially produced, systematic in their unequal distribution across the population, avoidable and unfair. The social determinants of health inequities are the social determinants of health – or the health-influencing social conditions in which people are born, grow, live, work, play and age – and the social processes that distribute these conditions unequally in society” (Victorian Health Promotion Foundation, 2015). Ensuring our health promotion practice is equitable and inclusive requires that we assess the relative accessibility of our activities to vulnerable or diverse populations and assess whether or not our strategies will have a differential impact on women or any other aspect of diversity within our society.

Aligned with Eastern Health strategic directionsEastern Health provides quality health care services across the Eastern Metropolitan Region. Eastern Health has an extensive interface with community members and other stakeholders and over 9,000 staff – the majority of which reside in the eastern region. This provides important opportunities to leverage relationships, build partnerships, scale up interventions and positively influence the health and wellbeing of communities across the eastern region. Health Promotion aims to identify opportunities to align and support Eastern Health’s vision for “Great care, everywhere, every time” and to ensure that our health promotion practice is in line with Eastern Health’s emphasis on building health literacy and contributing to research and evidence based practice (Eastern Health, 2017).

Creating empowermentA key tenet of health promotion is that it increases the capacity that individuals have over the determinants of their own health and wellbeing. It is in effect an empowering and enabling process and does not aim to reinforce situations where there is power-over or power-under others (Macy et al. 2014). Adopting a whole of ‘community empowerment’ and a strength based focus is an antidote to vicarious trauma and the effects of negativity and resistance to change that flow on from intergenerational trauma (Barstow, 2003).

Strengthening community leadershipSupporting leadership – by community organisations, services, businesses, the not for profit sector or individuals is a powerful way to effect change (Our Watch, 2017). Health Promotion will facilitate and support community leadership to challenge health behaviours. For example, the leadership shown by local footballers to challenge cultures of disrespect towards women has spread quickly throughout the local league and has now been used as a model in Victoria and interstate (ABC News, 2017).

Place based approachThis approach ensures our interventions are locally adapted and tailored to the conditions, context and dynamics of the local community and therefore more likely to create sustainable and inspired change (VicHealth, 2008). The Yarra Valley landscape is characterised by small towns, each with its own set of predominant local organisations, community leaders, community “influencers” and patterns of relationships and service provision. Community Health and Health Promotion hold an intimate knowledge of the community through the our existing community relationships.

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Innovative & StrategicBeing innovative and strategic is a vital way to ensure that our health promotion effort is targeted and well spent. Within the context of finite resources and the challenge of influencing large and well established systems, it is vital that health promotion is able to pilot new ways of doing things at the same time as building on the evidence base. Eastern Health, Health Promotion is aligned with the Vic Health definition of innovative health practice as “discovering how to accelerate health outcomes” (Vic Health, 2017).

Trauma informedIt is now well established that “Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional or spiritual wellbeing” (Substance Abuse and Mental Health Services Administration, 2017). At the interpersonal and community level, community trauma can be defined as “the product of the cumulative and synergistic impact of regular incidents of interpersonal, historical, and intergenerational violence and the continual exposure to structural violence”. (Pinderhughes, 2015). Health promotion has sought to engage with communities and particularly with men in ways that is trauma informed and will build their resilience through focusing on their capacity to become empowered and constructive agents for change.

Systems thinkingA system is “a group of interacting, interrelated and interdependent components that form a complex and unified whole” (Australian Partnerships Prevention Centre, 2017). Systems thinking is both a perspective on how a complex environment works and it is also a set of tools and processes that can be used to unpack or understand that particular system and design interventions.

CollaborativeThe principle of working collaboratively applies to both our role within Community Health at Eastern Health and our role in the community. Health Promotion seeks to partner with organisations that will enhance our collective impact and demonstrate our capacity to accelerate the outcomes achieved through group strategic effort.

Reorientating health servicesThe World Health Organisation urges health care organisations to move beyond providing health care for the ill and towards promoting and encouraging greater health and wellbeing (World Health Organization, 2017). Reorienting health services therefore involves creating health promoting environments for our own staff, ensuring that health promotion messaging and risk assessment is built into our services and linking across disciplines to ensure the impacts of health infrastructure are considered.

Culture of evaluation and reflectionHealth Promotion uses a variety of modes of evaluation to assess the impact of interventions and how these interventions have been designed. In the 2017 – 2021 Operational Plan the indicators used will be aligned with the Victorian public health and wellbeing outcomes framework (2016) and incorporate regional indicators as they are developed.

Strengths based This approach involves working with existing community and organisational resources, capacities, talents and strengths. It views community and individual capacity to transform environments and conditions as a fundamentally positive and empowering exercise. This approach is compatible with community mobilisation for prevention of violence work, as it brings a positive and enabling attitude to what is otherwise a very challenging subject (McCashen, 2017). It also involves looking at settings and environments and asking appreciative questions (Appreciative Inquiry Network, 2017) – for example, what is supporting

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physical activity in this community or in this school? How can we build or expand on these strengths?

Healthy and Active Living Respectful, Resilient and Healthy Communities

Promoting healthy food and drink choices.Ensuring that the healthy choice is the easy choice by increasing access and affordability of healthy foods and drinks where community

members spend most of their time.

Building capacity for respectful relationships and the prevention of violence against women.All community members are respectful and kind to one another and live free from all forms of violence.

Enabling environments that support physical activity.

All community members can easily participate in physical activity to increase

their health and wellbeing and decrease the chance of chronic disease.

Reducing harm from alcohol and other drugs.The Yarra Valley community works together to prevent the incidences of alcohol and other drug harm.

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Integrated Health Promotion in the Yarra Valley Priority Areas for 2017 – 2021

The Health Promotion team works by:With By

SettingsSchool and EducationEarly Years

Sporting Clubs

CommunityFood Supply

Target Populations

Children & families

Young peopleAboriginal and Torres Strait

Islander people

MenWomen

Vulnerable families

Our PrinciplesEquitable and inclusive

Alignment with EH strategic directions

Creating empowermentStrengthening

community leadershipPlace-based

Innovative & strategicTrauma informedSystems thinking

CollaborativeRe-orientating health

servicesCulture of evaluation

and reflectionStrength based

Health Promotion Priority Area – Healthy and Active Living Health Promotion Priority - 1

Promoting Healthy Food and Drink Choices

Health Promotion Goal Ensuring that the healthy choice is the easy choice by increasing access and affordability of healthy foods and drinks where community members spend most of their time.

Priority settings in the Yarra Valley Catchment

Schools, Sporting Clubs, Community, Social Media, Food Supply.

Target Populations Children & families, Young People, Aboriginal and Torres Strait Islander people, Men & Women.

Strategic Links:Yarra Ranges Council Public Health and Wellbeing Plan 2017 - 2021

Goal 1: People are able to access, prepare and eat fresh, nutritious foods.

Eastern Health Strategic Plan Vision - Great care, everywhere, every time.Strategic Priority -Healthcare excellence.

Victorian Public Health and Wellbeing Plan 2015 - 2019

Healthier eating and active living

Victorian Outcomes Framework

Outcome 1.3: Victorians act to protect and promote health

National Strategic Framework for Chronic Conditions 2017

Strategy 1.1: Promote health and reduce risk

Overweight and obesity prevalence is steadily rising in Australia. In 2015 it was found that nearly 2 in 3 Australian adults (63%) were overweight or obese and almost 1 in 4 children (25%) were overweight or obese (AIHW 2017). Overweight and Obesity is linked with serious health problems including a number of chronic diseases such as cardiovascular disease and type 2 diabetes (AIHW, 2017). More than 5% of the total disease and injury burden in Australia is attributable to overweight and obesity (AIHW, 2017) while 2% of the total burden is also attributed to inadequate fruit and vegetable consumption. The cost of overweight and obesity in Victoria has been estimated to be $14.4 billion (Access Economics, 2008). Locally 33% of Yarra Ranges residents are overweight or obese, 11% of residents consume sugar sweetened beverages every day and only 7.1% of residents are meeting the recommended serves of vegetables each day.

The Victorian Healthy Eating Enterprise (VHEE) established by the Victorian Government provides a coordinated platform to support healthy eating and promote access to nutritious food (Vic Health, 2017). The VHEE have identified seven priority areas of action:

1. Promote consumption of fresh fruit and vegetables.2. Reduce consumption of energy-dense and nutrient-poor food and drinks.3. Reduce consumption of salt and saturated and trans fats.4. Improve breastfeeding rates and maternal and infant nutrition.5. Increase the proportion of children and adults in the healthy weight range.6. Promote enjoyment of healthy foods. 7. Improve access to nutritious foods.

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Food security and healthy food access have been identified as ongoing concerns for the Yarra Valley community (Yarra Ranges Council, 2017). The local food system in the Yarra Valley specifically the barriers and enablers to improve access can be better explored and more clearly defined. The 2017 – 2018 Operational Plan will provide scope to gain a better understanding of the availability of healthy food in the Yarra Valley with a specific focus on increasing access to healthy food to all Yarra Valley residents, including access for the Aboriginal community and Emergency Food Relief. Health Promotion will simultaneously review and support the extension of health literacy education, through collaboration with Dietetics at Community Health to enable more members of the Yarra Valley communities to maintain a healthy weight or lose weight to prevent the development of chronic disease.

The following table sets a reach benchmark for access to Community Health Dietetics service from 1st July 2016 – 30th June 2-17:

Community Health 1st July 2016 – 30th June 2017

No. people who accessed our dietetics service 362No. of people who have accessed our dietetics service for weight management

111

No. of referrals to our dietetics service 272

Yarra Ranges Council, Inspiro and Community Health have agreed to work in partnership taking a collective impact approach to address healthy food and nutrition in the Yarra Valley. This Health Promotion Plan will look to build upon the positive work completed in the prior four year Integrated Health Promotion cycle regarding food and nutrition whilst exploring opportunities to work with new partners and settings. The primary focus of the work in the 2017-2018 Integrated Health Promotion Operational Plan will be to;

- Continue working with the schools setting, taking a whole of schools approach to address identified health and wellbeing issues.

- Explore opportunities to work in partnership on healthy eating with new settings in the Yarra Valley including sport and recreation settings.

- Develop a better understanding of the availability of healthy food in the Yarra Valley and take action to improve food access and decrease the incidences of food security.

- Increase Yarra Valley residents access and knowledge of Community Health services addressing healthy eating.

Health Promotion Priority - 2

Enabling environments that support physical activity

Health Promotion Goal All community members can easily participate in physical activity to increase their health and wellbeing and decrease the chance of chronic disease.

Priority settings of the Yarra Valley

Community, Schools, Sporting Clubs

Target Populations Children & families, Young People, Men & Women.

Strategic LinksYarra Ranges Council Public Health and Wellbeing Plan 2017 - 2021

Goal 6: People are physically activeGoal 7: People have access to active transport modes such as walking, cycling and public transport.

Eastern Health Strategic Plan Vision - Great care, everywhere, every time.Strategic Priority: Healthcare excellence.

Victorian Health and Wellbeing Plan 2015 - 2019

Healthier eating and active living

Victorian Outcomes Framework Outcome 1.3: Victorians act to protect and promote healthNational Strategic Framework Strategy 1.1: Promote health and reduce risk

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for Chronic Conditions 2017

Physical inactivity is one of the most significant contributors of ill health and disease globally (Lee et al, 2012). Physical activity has overwhelming health and wellbeing benefits and is linked with both improved physical and mental health and wellbeing (VicHealth, 2016). Statistics from 2014-2015 revealed that only around half (56%) of Australians had participated in sufficient physical activity in that week (Australian Bureau of Statistics, 2015) and 15% had participated in no physical activity at all (Australian Bureau of Statistics, 2015). In 2011-2012, 64% of Victorians met the physical activity guidelines (State of Victoria, 2014). The total financial costs of physical inactivity in Australia were estimated to be $13.8 billion (Medibank, 2008). Reducing physical inactivity has the potential to reduce healthy sector costs by approximately $96 million a year (VicHealth, 2016) through decreased hospital admissions and services.

The VPHWP identifies a number of strategic directions to address physical inactivity including:- Encouraging and supporting people to be as physically active as often as possible

throughout their lives. Strategies may include active transport (such as walking or cycling to work), neighbourhood design that promotes activity and social connectedness and participation in sport and recreation.

- Encouraging interaction with nature in Victoria’s parks and open spaces.

The Yarra Ranges Council (2017) have identified an opportunity to implement a large scale program designed to help enable walking as an easy choice for residents in the Yarra Ranges. The upward rising trajectory of technology use and the shifting norms towards sedentary lifestyles at home and at work is significantly contributing to the culture of physical inactivity. Yarra Ranges Council, Inspiro and Eastern Health Health Promotion through community led and driven action aim to challenge this cultural shift.

The Health Promotion team has a strong existing relationship with AFL Yarra Ranges having previously had a number of successes with the Be the Change! Project. A new project partnership project with the AFL Yarra Ranges will be developed to simultaneously increase women’s participation in support as well as address a range of other risk factors within this setting. The Health Promotion team will also work with Community Health to review and expand the current reach of its physical activity programs to further prevent chronic conditions and avoid potential hospitalisations from the Yarra Valley community. In the most recent 12 month period (1st July 2016 – 30th June 2017) 284 clients participated in any of our physiotherapy facilitated physical activity groups.

In summary, the planned strategies for the 2017-2018 Integrated Health Promotion Operational Plan include:

- Shared planning and action with Yarra Ranges Council and Inspiro around physical inactivity levels in the Yarra Valley.

- Continue working with the schools setting, taking a whole of school approach to address identified health and wellbeing issues.

- Increasing female participation in sport and community leadership in partnership.- Expanding the scope of physical activity programs within Community Health, including

the reorientation of services to promote the conservative management of osteoarthritis.

Health Promotion Priority - 3

Reducing harm from alcohol and other drugs.

Health Promotion Goal The Yarra Valley community works together to prevent the incidences of alcohol and other drug harm.

Priority settings of the Yarra Valley

Community, Schools, Sporting Clubs, Social Media.

Target Populations Young People, Aboriginal and Torres Strait Islander 12 | P a g e

community, Parents, Men & Women.

Strategic LinksYarra Ranges Council Public Health and Wellbeing Plan 2017 - 2021

Goal 3 - People who use alcohol do so in moderation and safety.Goal 12 – Every child and young person can thrive and reach their potential.Goal 13 – Older people enjoy active and healthy lives.

Eastern Health Strategic Plan Vision - Great care, everywhere, every time.Strategic Priority: Healthcare excellence.

Victorian Health and Wellbeing Plan 2015 – 2019

Tobacco free living Reducing harm from alcohol and other drugs

Victorian Outcomes Framework Outcome 1.3: Victorians act to protect and promote health.

National Strategic Framework for Chronic Conditions 2017

Strategy 1.1: Promote health and reduce risk.

The 2017 – 2021 Integrated Health Promotion Plan will focus on two areas of drug use within the Yarra Valley community – alcohol and tobacco. Alcohol and other drug use in Australia continues to contribute a significant burden to the health care system.

Fewer people are smoking every day. In 1991, 24% of people aged 14 and over smoked compared with 13% in 2013 (Australian Institute of Health and Welfare, 2016). However the cost of smoking to the health sector is still unreasonably high hence the pressure to reduce smoking rates in populations that have shown resistance to change (Cancer Council, Victoria, 2007). Rates of smoking in the Aboriginal and Torres Strait Islander Community are significantly higher than the mainstream community (Cancer Council Victoria, 2017). The Victorian Public Health and Wellbeing Outcomes Framework (2016) seeks to reduce the number of adolescent and adult smokers by 30% by 2025.

20% of the national self-harm burden, 14% of the interpersonal violence burden and 7.5% of the unintentional injury burden (other than road transport) is due to alcohol use (Institute for Health Metrics and Evaluation 2013). Over 1 in 4 Australian adults consumed alcohol at levels which put them at risk of short-term harm in 2013 (Australian Institute of Health and Welfare, 2016). 15% of Victorian 18–24 year olds drink alcohol at risky or high-risk levels for short-term harm at least weekly (Department of Health, 2014). Key challenges to reducing harm from alcohol include the availability of liquor license and planning provisions by which they are granted and the normative culture around drinking that has become entrenched in Australian society (VicHealth, 2014). The National Alliance for Action on alcohol consists of more than 40 organisations working to prevent and reduce harm from alcohol use – with a particular focus on policy and increased government action (National Alliance for Action on Alcohol, 2017).

Through community consultation and local service provider networks during 2016, harmful alcohol use was noted as a priority issue of concern for Health Promotion. There are significant gaps in the Yarra Valley community in terms of:

Inter-sectoral collaboration to prevent harm from alcohol and other drugs. Community based prevention and harm reduction campaigns. Limited service access for family members seeking family support. Challenges with access to Alcohol or other drug treatment services and service

coordination (EACH, EMR Alcohol and other drug Catchment Plan, 2014).

Data for the Yarra Ranges LGA shows the following trends:

Indicator – Yarra Ranges Trend (2011 to 2015)

Data SourceNo. of hospital Increasing 2014/2015 - 838 http://aodstats.org.au/

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presentations 2013/2014 - 6732012/2013 - 5682011/2012 - 548

VicLGA/

Rates of serious road injury (per 10,000 in High Alcohol Hours)

Decreasing 2014/2015 – 2.92013/2014 – 3.62012/2013 – 4.22011/2012 – 4.0

http://aodstats.org.au/VicLGA/

Alcohol Assault Rate (rate per 10,000 in High Alcohol Hours).

Stable 2014/2015 – 0.92013/2014 – 0.92012/2013 – 0.92011/2012 – 0.7

http://aodstats.org.au/VicLGA/

Definite Alcohol Related Family Violence Incidents (per 10,o00)

2014/2015 – 9.52013/2014 – 132012/2013 – 8.62011/2012 – 9.5

http://aodstats.org.au/VicLGA/

The Eastern Metropolitan Region alcohol and other drugs Catchment planning process revealed the extent to which families and children are affected in this region. Based on Australian Drug Information System data (2014/15 financial year), close to a third of registered alcohol and other drugs clients have dependent children. Whilst not causal factors, evidence suggests that in individual cases of family violence, mental illness and alcohol and other drug use are risk markers for increased severity and frequency of family violence. In relation to alcohol, the evidence shows that the severity and risk of injury is increased; women’s rehabilitation from drug and alcohol problems is directly related to whether they are able to escape domestic violence; and that perpetrators use their substance use as a ‘tactic of abuse’ to increase fear and control (EACH, EMR AOD Catchment Plan 2016- 2018). These links suggest that a multi-pronged strategy, for the prevention of violence against women in tandem with reducing harm from alcohol may have positive and reinforcing outcomes for community health and wellbeing in the Yarra Valley.

VicHealth has strongly encouraged public health practitioners to adopt an Alcohol Cultures Framework when designing health interventions to reduce harm from alcohol. Vic Health defines alcohol culture as:

..the way people drink, including the social norms, attitudes and beliefs around what is and what is not socially acceptable for a group of people before, during and after drinking. (Vic Health, 2016).

The Alcohol Cultures Framework (Vic Health, 2016) suggests a new culture where harm from alcohol is prevented. This new culture would be characterised by the following:

A supportive physical and/or social environment where people do not feel pressure to drink.

When alcohol is consumed it is done at low levels of risk. Social pressures that support low-risk drinking and discourage high-risk drinking. Occurrences of drinking are reduced. Intoxication is socially rejected.

The focus on drinking culture and “subcultures” within different groups in Australian society has been a recent focus and investment of Vic Health. This is because the “…risky consumption and related harms appear as “clusters of problems”, affecting different groups in different ways. Harms may stem from long-term or acute use, and different groups are at risk of different patterns and types of harms” (Vic Health, 2015a). Some pockets of the Yarra Valley experience significant social disadvantage, isolation and unemployment (Yarra Ranges Council Health Profile, 2017) where as others experience relative affluence and are connected to the thriving viticulture. Another important implication in the diversity of the Yarra Valley communities is differences in health literacy. Guidelines to inform low risk drinking that are

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set nationally have been shown to be better understood by better-educated and higher-socio economic status individuals (Vic Health 2015a).

The 2017 – 2018 Operational Plan will focus on the following areas for strategic action to reduce harm from Alcohol and Tobacco use:

Sporting clubs: co-designing a program with AFL Yarra Ranges based on enhancing community leadership for change. This initiative will include looking at drinking cultures within clubs, knowledge of the risks of short term and long term drinking as well as strengthening respectful relationships, promoting mental health, supporting smokers to quit and increasing healthy eating.

Supporting schools to implement the current curriculum around alcohol and other drugs and improve their cohesive response through the Achievement Program. Health Promotion will also trial the delivery of community health support and services to parents in the school setting.

Investigating the potential for a Yarra Valley based cross sectoral collaboration to reduce alcohol harm with a review of available evidence and successful initiatives such as Communities that Care (Communities that Care, 2017).

Investigate the potential for increasing the scope of tobacco cessation support and tobacco uptake prevention strategies with the Aboriginal Health team, external stakeholders and Community Health services.

Health Promotion Priority Area – Respectful, Resilient and Healthy Communities Health Promotion Priority - 4 Building capacity for respectful relationships and the

prevention of violence against women.Health Promotion Goal All community members are respectful to one another and live

free from all forms of violence.Priority Settings of the Yarra Valley

Schools, Community, Sporting Clubs, Social Media.

Target Populations Children & families, Young People, Aboriginal and Torres Strait Islander people, Men & Women, Vulnerable populations.

Strategic LinksYarra Ranges Council Public Health and Wellbeing Plan 2017 - 2021

Goal 16: Women and children live free from abuse and violence through a culture of gender equity and respect.

Eastern Health Strategic Plan Great care, everywhere, every time.Strategic Priority -Healthcare excellence.

Victorian Public Health and Wellbeing Plan 2015 - 2019

Preventing Violence and Injury.

Victorian Outcomes Framework

Outcome 2:1: Victorians live free from abuse and violence.

Free From Violence – Victoria’s Primary Prevention Strategy

Outcome 1.Victorians hold attitudes and beliefs that reject gender inequality and violenceOutcome 2. Victorians actively challenge attitudes and behaviours that enable violence

Together for Equality and Women experience increased equity and decreased

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Respect discrimination.Women can equitably participate in inclusive and liveable communities.Women benefit from coordinated, evidence informed action to prevent violence.Prevention initiatives are informed by voices of women.

Violence against women is the single most important risk factor for illness and disease for women aged 15 – 44 in Australia (Our Watch, 2017). Hospital admissions related to mental health episodes or crisis, alcohol or other drug use, injury and chronic disease can often be linked to family violence but often go unreported or undetected. Aboriginal and Torres Strait Islander women are 35 times more likely to be hospitalised as a result of family violence (Our Watch, 2017a). Many women that experience family violence also have children in their care. The prevention of violence against women is an issue of national and critical importance. The health, administration and social welfare costs of violence against women have been estimated to be $21.7 billion a year (Our Watch 2017). Violence against women is the single largest driver of homelessness for women and results in a police call-out on average once every two minutes across Australia (Our Watch, 2017).

In 2016 the Royal Commission into Family Violence handed down 226 recommendations to the Victorian government, agencies and community members. These recommendations widely called for system reform, investment in primary prevention and thorough challenges to the normative cultures that condone or support violence (Royal Commission into Family Violence, 2016). In early 2017 Victoria also launched its state-wide strategy – Free from Violence which establishes a clear framework within which the prevention of violence against women can be achieved (State of Victoria, 2017) not long after releasing Victoria’s first Gender Equality Strategy – Safe and Strong (State of Victoria, 2017).

Eastern Health has had a long standing commitment to the primary prevention of violence against women through its commitment to the eastern region Together for Equality and Respect Strategy and Action Plan (Women’s Health East, 2013). “Despite significant advances, inequalities for women and girls persist across many areas of Australian life, gender norms and stereotypes remain powerful, and discrimination on the basis of sex and gender still occurs in many contexts.” (Our Watch, 2017). The Our Watch Handbook for the Primary Prevention of Violence Against Women directs public health practitioners “…to change the norms; practices and structures that produce gender inequality and underpin the drivers of violence against women” (Our Watch, 2017). This framework proposed four strategies to prevent violence against women in Australia.

Promote women’s independence and decision making. Challenge condoning of violence against women. Strengthen Respectful Relationships. Challenge Gender Stereotypes.

Family violence is a well-known issue in the Yarra Valley community (Yarra Ranges Council, 2017). A successful range of initiatives was implemented by Health Promotion in the 2016/2017 year to activate leadership and support community efforts to prevent family violence. Approximately 177,000 people in the Yarra Valley and Eastern Metropolitan were exposed to Health Promotion Prevention of Violence against Women activities in the 2016/2017 year.

In the Yarra Valley community several strategic initiatives were established including the Healesville Change the Story Partnership, Voices of Women (a new organisation to empower women of the Yarra Valley) and the Healthy Mates – Upper Yarra Initiative (focusing on men’s health and challenging male violence in the upper Yarra). A pilot program was developed in partnership with Healesville High School for Year 9 students – Healesville This Girl Can and the foundations were established for a strengthening women forum to be held in Healesville 2018. Bystander training, community breakfasts, media articles and local advocacy made a

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significant contribution to local community knowledge and discussion around this topic. For example, Healesville Change the Story was invited to showcase its work to the Yarra Ranges Council in early 2017. Additional to this local focus, Eastern Health partnered with Women’s Health East, COLES, AFL Yarra Ranges, the Eastern Football League, Inspiro and Yarra Ranges Council to hold the “Be the Change! forum”. This inspirational forum attracted 180 attendees, including representatives from club committees from football and netball clubs across the eastern region. The forum encouraged community leaders to continue challenging gender stereotypes and create positive club cultures where respect and equality are paramount.

The 2017 – 2018 Operational Plan has a strong focus on:- Continuing to support place based partnerships for the prevention of violence against

women, ensuring sustainability of local initiatives. - Re-orientating Community Health service around the engagement of fathers pre and

post-natally to ensure engagement is continuous and effective around key developmental points in the family where family violence may become evident.

- Initiate a focus on Early Learning Centres and supported playgroups to challenge gender stereotypes in the formative years.

- Supporting whole of community, whole of school approaches to Respectful Relationships, including community based programs for young women and young men delivered in partnership with Community Health services.

- Encouraging women’s participation in community leadership and sport in the Eastern Football League.

Conclusion

The 2017 – 2021 Integrated Health Promotion Plan for Eastern Health provides an important opportunity for Eastern Health to actively influence the prevalence of behaviours in the Yarra Valley communities that increase the likelihood of future hospital admissions and the expected burden of chronic disease within the scope of our current Clinical Operations Plan (2014 – 2024). Through effective partnerships, multi-risk factor approaches and interventions across settings we expect to accelerate and improve health outcomes in the Yarra Valley Catchment.

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