WA Health Promotion Strategic Framework 2007 2011

Western Australian
Health Promotion Strategic

Framework 2007-2011
HP10196 JUN’07 21939
Prepared by the Population Health Policy Branch

Health Policy and Clinical Reform Division
© Department of Health 2007
Western Australian Health Promotion Strategic Framework 2007-2011
Western Australian
Framework 2007-2011
i
The Western Australian Health Promotion Strategic Framework 2007-2011 progresses and
supports the commitments in the Western Australian Department of Health’s Strategic
Intent 2005-2010 across the six key strategic areas:
Healthy communities – increasing awareness of the social determinants of health and

the importance of a good start in life, and identifying priorities for health promotion
to promote healthy lifestyles and empower communities and individuals to adopt
healthier lifestyles.
Healthy leadership – providing a vision for the prevention of chronic disease and
injury, and identifying opportunities for WA Health to advocate for prevention at
national, state and regional level.
Healthy partnerships – identifying the need for strong relationships and collaboration
with other agencies inside and outside the health system, at national, state and local
level, to ensure the effective delivery of the integrated multi-component programs
needed to change behaviour.
Healthy hospitals – identifying a greater role for hospitals and health services in
prevention and early intervention and for better links with risk reduction services
outside the acute sector.
Healthy workforce – improving the skills, capacity and willingness of the health sector
to engage in prevention through risk assessment and health promotion.
Healthy resources – identifying the need for longer-term planning and resource
allocation for prevention to allow sustained effort and sustainable and equitable
access to health promotion programs and interventions.
ii
Foreword
WA Health is committed to supporting healthier, longer and better lives for all Western
Australians. The Department of Health’s Strategic Intent 2005-2010 and the recently released
WA Health Operational Plan 2007-08 both affirm the need to promote health through a greater
emphasis on health promotion and early intervention.
The Western Australian Health Promotion Strategic Framework 2007-2011 outlines the
strategic directions for promoting healthier and safer lifestyles for the Western Australian
population over the next five years. The framework will also inform WA Health’s purchasing of
health promotion campaigns and programs from the non-government sector.
The Western Australian Health Promotion Strategic Framework 2007-2011 takes a common
behavioural risk factor approach and describes how health promotion can improve health
outcomes for the whole population, specific sub populations and individuals at greatest risk of
harm from chronic disease and injury.
While the framework is not intended to be a prescriptive action plan, I encourage health
services and key partners to build its strategic directions and approaches into their operational
and work plans in a way that is pertinent to their work environment and reflects the needs of
the communities they service.
Achieving the agenda outlined in the framework will require a long-term commitment,
involvement of all parts of the health system, innovation and effective partnerships and
collaboration.
It is important to note that we start from a relatively strong position in Western Australia.
Through our long history of innovative health promotion we have had many successes, including
a reduction in overall smoking rates and increased fruit and vegetable consumption. Extensive
health promotion work is currently being undertaken across the health system to address health
inequalities and reduce the burden of chronic disease and injury. Despite these significant
achievements, there remains a considerable amount of work to be done.
The Western Australian Health Promotion Strategic Framework 2007-2011 has been a
collaborative project, which has benefited from the expertise of partners within WA Health and
across the non-government sector. Its development reflects the cooperation and partnerships
that exist within the Western Australian health system. I thank the many people involved in the
development of this strategic initiative.
I commend the Western Australian Health Promotion Strategic Framework 2007-2011 to you
and look forward to seeing partners across Western Australia take this work into the future.
Jim McGinty
MINISTER FOR HEALTH
iii
iv
Contents
Page no.
Background and rationale 1

The need for a Western Australian health promotion strategic framework 1
About the Western Australian Health Promotion Strategic Framework 2007-2011 1
The burden of chronic disease and injury in Western Australia 4
Determinants of chronic disease and injury 6
Savings possible from health promotion approaches 11
Future directions 12
Key strategic approaches 14
Achieving a healthier and safer lifestyle 19
Preventing smoking 21
Healthy eating 26
Physical activity 31
Healthy weight 36
Low risk alcohol use 42
Preventing injury 47
Organisational enabling and implementation actions 55
Appendices
Appendix 1: Background to the development of the Western Australian
Health Promotion Strategic Framework 2007-2011 58
Appendix 2: Relevant endorsed National and State strategies/action plans 61
Appendix 3: Health promotion and risk reduction interventions across
the continuum of care 63
References 64
v
vi
Background and rationale
The need for a Western Australian health promotion

strategic framework
While there has been considerable improvement in the life expectancy of most Western
Australians over the last 20 years, the health system is experiencing increasing demand for
its services[1]. There are significant and widening gaps in health status and life expectancy
between different segments of the community, particularly between Aboriginal and non-
Aboriginal people, and between the most and least socio-economically disadvantaged groups[2].
Preventable chronic diseases and injury are major causes of mortality, morbidity and disability
and their management and treatment impose a considerable burden on the Australian health
system. It has been estimated that nationally, more than 80% of the burden of disease and
injury[3] and 70% of health care expenditure is due to chronic disease and injury[4]. In addition,
chronic disease and injury are strongly linked with poor mental health[5].
Much of the premature mortality and morbidity associated with chronic disease and injury is
preventable[6]. Investment in sustained, well-targeted health promotion and early intervention
can reduce the prevalence of these conditions, delay their development and reduce associated
complications, thereby improving health outcomes and reducing the burden on the health
system[7, 8].
Current international and national approaches, including the National Chronic Disease
Prevention Strategy, recommend a ‘cluster’ approach to the prevention of chronic diseases.
This involves targeting the common behavioural risk factors (physical inactivity, poor nutrition,
smoking and harmful alcohol use) through comprehensive population based approaches.
The need for increased investment in, and more effective approaches to, the prevention
of chronic disease and injury has been a major component of the health reform in Western
Australia[9, 10]. The Western Australian Department of Health’s Strategic Intent 2005–2010[9]
reaffirmed the need to increase the focus on the promotion of health and wellbeing; through
better awareness of the social determinants of health and the importance of a good start in
life, health promotion to ensure adequate physical activity and nutrition and continued efforts
to reduce smoking. Prevention and early intervention are one of the three overarching themes
identified in the WA Health Operational Plan 2007-08.
About the Western Australian Health Promotion Strategic

Framework 2007-2011
The Western Australian Health Promotion Strategic Framework 2007-2011 (WA HPSF) outlines
the key directions for the promotion of healthier and safer lifestyles for the Western Australian
population over the next five years. It focuses on a number of risk factors and injuries, and
identifies health promotion issues important for the whole population, groups and individuals at
increased risk of or with chronic disease and injury.
1
The strategic directions outlined in the WA HPSF were identified through systematic review of
information about the burden of disease, prevalence and trends in lifestyle and behavioural
risk factors, recommendations by recent national and state strategies and action plans, studies
of the effectiveness of available interventions and local expert advice. Information about the
development process is provided in Appendix 1.
The WA HPSF is intended to complement existing national and state risk factor, healthy
lifestyle, chronic disease prevention and injury prevention strategies and action plans (see
Appendix 2 for a listing of relevant WA Health endorsed national and state plans). Some plans
provide more specific recommendations for progressing the priority areas outlined here.
Addressing the considerable health inequalities experienced by Aboriginal people is a high

priority for WA Health. The WA HPSF endorses the actions outlined in the Strong Spirit Strong
Mind: Western Australian Aboriginal Alcohol and Other Drugs Plan 2005–2009 and the Western
Australian Aboriginal and Torres Strait Islander Health Promotion Action Plan 2005–2008.
Not all chronic conditions are addressed in the WA HPSF. It does not address:
Mental health promotion.
Sexual health and communicable disease: priorities for action are outlined in four state
plans and strategies covering Hepatitis C, HIV/AIDS, sexually transmitted infections and
Aboriginal sexual health (Appendix 2).
Screening for early detection of cancer.
Mental health promotion is a critical component of effective approaches to the prevention of
ill-health, injury and chronic disease. Stress and depression are risk factors for chronic disease
and injury, and mental health is an important influence on the adoption of healthier lifestyles,
avoidance of injury and health outcomes associated with chronic disease.
Effective prevention approaches must include mental health promotion and illness prevention
strategies. The Mental Health Division has developed the Western Australian Mental Health
Promotion, Illness Prevention and Early Intervention Strategic Framework 2007–2009, a
framework for progressing mental health promotion and illness prevention in Western Australia.
The WA HPSF is underpinned by two key health promotion approaches:
1. Broadening the scope of health promotion

There are significant opportunities for health gain through the use of health promotion
approaches in the development and management of chronic disease and injury. Risk reduction
or preventiona approaches can reduce the risk of injury or disease, prevent or delay the
development of disease among those at higher risk, minimise complications and improve health
outcomes associated with both established chronic disease and injury.
The WA HPSF takes a population based approach to ensure that appropriate prevention
activities occur at all stages of the continuum from wellness to ill health. Figure 1 identifies
potential intervention points for health promotion activities. Further information is provided in
Appendix 3.
a
The terms ‘prevention’ and ‘risk reduction’ are used in the WA HPSF to avoid the potential confusion caused
by different usage of the terms primary, secondary and tertiary prevention in different parts of the health
system.
2
This whole of system approach shares the responsibility for health promotion across the health
system – that is, “prevention becomes everybody’s business”.
Figure 1: Prevention across the continuum of wellness and disease/injury
Population by stages of disease continuum

Well populations At risk Injury Controlled chronic
disease
Primary prevention Early detection Disease management
- Promotion of - Screening - Treatment and - Continuing Care

healthy behaviours - Case finding Acute Care - Maintenance
and environments - Complications
across life course - Periodic health - Rehabilitation
examinations management
- Universal - Self Management
and targeted - Early intervention
approaches - Control risk factors
-lifestyle and
medication
- Public health - Primary health - Primary health - Primary health
- Primary health care care care
care - Public health - Specialist services - Community care
- Other sectors - Hospital care - Specialised
services
“Hospitals”
Health Promotion Health Promotion Health Promotion Health Promotion
Prevent movement to Prevent progression to Prevent/delay

the “at risk” group established disease and progression to
hospitalisation complications and
prevent readmissions
Adapted from Preventing Chronic Disease: A Strategic Framework, page 6[6]
2. A comprehensive approach to health promotion

The WA HPSF recognises the complexity of changing health related behaviours and the need
for a comprehensive approach to the prevention of chronic disease and injury. As illustrated
in Figure 2, this includes population based policy and legislative approaches that create
environments that support better health; lifestyle and behavioural approaches in community
and health care settings that improve health communication, health education and skills
development; and community development and engagement.
3
Figure 2: Framework for comprehensive health promotion action
Populations Populations, groups and individuals Individuals
Infrastructure and Communication Health education Community Health care

systems change and empowerment and health interactions
development
Policy Health information Knowledge Engagement Systematic and
opportunistic
Legislation Behaviour change Understanding Community action risk reduction
campaigns approaches
Organisational/ Skills development Advocacy
environmental
change
Adapted from Keleher and Murphy, 2004, page 160[11]
A comprehensive health promotion approach will include a broad range of intervention types,
such as social marketing and mass media campaigns, education and skill development programs,
environmental supports, organisational policy, legislation, community action, workforce capacity
building, early detection of high risk, prevention in clinical settings, safer products and settings,
advocacy, and sponsorship.
The burden of chronic disease and injury in Western Australia

Chronic disease
As shown in Figure 3, ischaemic heart disease, stroke, type 2 diabetes, certain cancers and
chronic obstructive pulmonary disease (COPD) are some of the leading contributors to the
burden of disease[12, 13]. In 2000, these conditions were responsible for almost half of the total
burden of disease in Western Australia[13]. In 2005, the hospitalisation costs for a number of key
preventable chronic diseases in Western Australia were approximately $114 million, comprising
cardiovascular disease ($47 million), preventable cancers ($41 million), diabetes ($17 million),
lung cancer ($6 million) and asthma ($3 million)[12].
Figure 3: Burden of disease (DALYSb) for major disease groups, WA, 2000[13]
DALYS (disability adjusted years) is a composite estimate of the burden of disease that includes years of life
b
lost and years of life lost due to disability.
4
Injury-related harm
Injuries accounted for 11% of the total burden of disease in Western Australia in 2000[14]. The
leading causes of injury-related harm were road crashes, suicide, self-harm and falls (Figure 4).
Between 1989 and 2000, transport and self-inflicted injuries accounted for the greatest number
of injury deaths, while falls and other unintentional injuries caused the highest number of
hospitalisations[15].
In 2005, the Western Australian hospitalisation costs for injury were $41 million[12]. A 2003
study of total health system costs (including but not limited to hospitalisation) found that the
leading contributors to injury-related costs were falls (25%), injuries inflicted by another (24%),
transport injuries (20%) and other unintentional injuries (18%)[16].
Figure 4: Burden of disease due to different injuries, WA, 2000[14]
Aboriginal people have disproportionately higher rates of chronic disease and injury than their
non-Aboriginal counterparts. Age-standardised hospital separation rates for many conditions,
including injury, are higher for the Aboriginal than non-Aboriginal population (Figure 5).
Hospitalisation rates for chronic disease and injury are higher in rural than metropolitan
areas (Figure 6) and among those living in the most socio-economically disadvantaged
circumstances[12].
Figure 5: Age-standardised hospital separation rates by Aboriginality, WA, 2005[12]
5
Figure 6: Age-standardised hospital separation rates by urban/rural, WA, 2005[12]
Determinants of chronic disease and injury

Many environmental, social and lifestyle factors enhance or reduce the risk of chronic disease
or injury. These determinants are linked in a complex causal pathway across the life course at
individual, community and societal level. Relevant to the WA HPSF are:
Early life and development of resilience.
Social and environmental factors.
Lifestyle behaviours.
Mental health.
Early life and development of resilience

Early life environment and experiences, particularly in utero and from birth to four years old,
have a profound impact on development of mental and physical resilience. They also affect
subsequent responses to environmental factors and development of behaviour patterns that
influence people’s risk of injury or chronic disease[17].
Factors influencing early life development and resilience include:

Peri-natal maternal physical health, mental health and lifestyle and their impacts on
foetal and infant exposure to tobacco, alcohol, poor nutrition and unsafe environments.
Childbirth weight.
Duration of breastfeeding, introduction of solids and development of healthy eating
habits and preferences.
Development of fundamental movement skills and healthy physical activity habits and
preferences.
Childhood physical environments safe from infection, tobacco smoke, injury and
poisoning.
Nurturing family, school and neighbourhood environments that support parent infant
attachment and positive social and emotional wellbeing and social skills development.
6
These factors can have a cumulative effect on later behaviour, health and risk of injury. For
example:
Lifestyle related behaviours learnt during childhood and adolescence influence later
attitudes and behaviours and can be difficult to change in adult life.
Children who become overweight or obese due to poor lifestyle habits are more likely to
be obese in adulthood and have a much higher risk of developing chronic diseases such as
type 2 diabetes[18].
The period from pre-conception through childhood provides a time limited opportunity to
influence the learning, behaviour, health, and wellbeing of the whole population. A good
start is fundamental to the achievement and maintenance of health and avoidance of injury
throughout the life cycle, and extending into future generations.
Social and environmental factors

The World Health Organization[19] identified social and environmental factors as the basis
of much of the inequality in world health. The most pressing health inequalities in Western
Australia are those experienced by Aboriginal people, those living in socio-economically
disadvantaged circumstances and those living in rural and remote areas.
Many of the underlying causes of poor health derive from the social, environmental, economic
and cultural contexts in which people live, work and play. The social determinants of health
are increasingly recognised as a priority area for health in their own right, but are also very
much embedded in the environments that shape behavioural risk factors and inequalities in
health. Social determinants are often defined by examples of what they are or by where they
fit relative to other influences of health. Those most commonly identified include: where a
person lives, income and educational attainment, employment status, access to transport and
level of social support. Psychosocial factors such as stress, control over one’s life and social
networks are also emerging as strong predictors of health and wellbeing[20].
A range of environmental factors also impact on health behaviour, through defining access
to healthy food, opportunities for physical activity, exposure to harmful environments and
conditions, opportunities for risk taking behaviours, and social norms and expectations.
The Australian Institute of Health and Welfare’s conceptualisation of health (Figure 7) places
the social and environmental determinants within the broader range of factors that can impact
on health behaviours and outcomes.
7
Figure 7: Conceptual framework for determinants of health
General Socioeconomic Health Biomedical

background characteristics behaviours factors
factors Education Dietary Body weight
Culture behaviour
Employment
Resources Blood pressure
Income Physical
Systems
activity Blood
Policies Family,
Wealth neighbourhood Tobacco use cholesterol
Social cohesion Access to Alcohol Glucose
Media services consumption tolerance Individual and
Other Use of illicit population
Other Immune status
Environmental drugs health
factors Knowledge and Other
attitudes Vaccination
Landscape status
Climate
Chemical Sexual
Human-made practices
Ionizing Other
radiation Psychological
Infectious effects
agents Safety factors
Individual makeup: physical and psychological (genetics,

inter-generational, ageing and life course influences)
Adapted from Australia’s Health: the ninth biennial report of the Australian Institute of Health and Welfare,
2004, page 123[21]
Changing these determinants requires the integrated efforts of all human service agencies at
both Commonwealth and State level. The health sector can take a leadership role in brokering
partnerships and shaping policy that affects these determinants and tailor services to those
experiencing the greatest disadvantage.
Lifestyle behaviours
Several lifestyle behaviours are risk factors for a number of the chronic conditions that are the
focus of the WA HPSF, both for preventing the development of disease as well as slowing the
development of symptoms and complications. These include:
smoking
poor eating habits
inactive lifestyle
harmful alcohol use.
Some or all of these behavioural risk factors also contribute to biomedical risk factors for the
major chronic diseases, notably obesity, hypertension, elevated blood lipids and impaired
glucose tolerance.
8
The overall burden of chronic disease and injury in Western Australia due to these key risk
factors is indicated below. In 2000, almost $116 million in Western Australian hospitalisation
costs were attributed to obesity and overweight, inadequate fruit and vegetable consumption,
physical inactivity and high blood cholesterol[12].
Figure 8: Total disease burden attributed to selected risk factors by gender, WA, 2000[12]
Lifestyle behaviours are amenable to change, and for this reason are an important focus of
health promotion effort to prevent chronic disease and injury. A significant proportion of
Western Australians are putting their health at risk through unhealthy lifestyle behaviours:
Smoking 13% of those aged 16 years and above smoke every day[22].
Unhealthy diet More than four in five adults (84%) are not eating the recommended daily amount
of vegetables and more than one in two (52%) are not eating the recommended
daily amount of fruit[22].
7% of 4-11 year olds and over three-quarters (77%) of 12-17 year olds are not
eating the recommended daily intake of fruit[22].
43% of 4-7 year olds, 66% of 8-11 year olds and almost three-quarters (72%) of
12-17 year olds are not eating the recommended daily intake of vegetables .
[22]
46% of mothers are still breastfeeding at 26 weeks, and only one per cent
exclusively breastfeed their infant at six-months[23].
Physical 55% of adults aged 16 years and over report insufficient physical activity for health
inactivity benefit[22].
76% of children aged 5-12 years report insufficient physical activity[22].

Harmful alcohol 11% of adults drink at levels that put their health at risk in the long term, while
use 39% drink at levels that put them at risk of immediate harm[24].
One in four 12 to 17 year old school students drink at levels that put them at risk
of immediate harm[25].
Overweight and 60% of adult males and 43% of adult females aged 16 years and over are overweight
obesity or obese[22].
Between 1985 and 2003, overweight and obesity more than doubled in Western
Australian male school children aged 7-15 years (9% to 23%) and almost tripled in
female school children of the same age (11% to 30%)[123].
9
Where there are multiple risk factors, the risk of developing disease or experiencing injury is
substantially higher. It was estimated that in 2004/05, 44% of Australian adults had at least
three of the modifiable behavioural and biomedical risk factors identified in Table 1[2].
Mental health
There is strong evidence that poor mental health is an important risk factor for chronic disease
and injury, and for the health outcomes associated with these conditions.
Many of the early life development factors that contribute to poor mental health also
impact on the likelihood of developing other problems such as conduct disorders,
antisocial behaviour, risk taking behaviours, suicide and later adoption of smoking
and harmful drinking. These are particularly important where there is cumulative
disadvantage (such as Aboriginal people)[26].
People who have a mental illness are more likely to have physical illnesses (such as type
2 diabetes, high blood pressure, heart attack and stroke) that are related to behavioural
risk factors (smoking, alcohol and drug abuse, obesity, poor diet and obesity)[5].
Prolonged stress, depression, social isolation and lack of social support can increase the
risk of these conditions[27].
People who have a mental illness are also at increased risk for all types of injury,
particularly drug-related poisoning and injuries inflicted by another person[5].
Poor mental health can diminish the capacity to implement appropriate risk reduction
strategies, such as physical activity[28].
People with chronic disease are much more likely to develop depression and other mental
health problems than the general population. In addition, poor mental health can slow
recovery of physical conditions[29].
Cluster of determinants
A number of behavioural, mental health and biological determinants are common to certain
preventable chronic diseases (see Table 1[30]). Many of these shared risk factors also contribute
to the occurrence of injuries. For example, decreased mobility, poor muscle strength and poor
balance due to an inactive lifestyle contribute to falls in older adults. The risk of a fracture
from a fall will be greater in people with fragile bones due to osteoporosis.
10
Table 1: Links between conditions, the associated risk factors and determinants
Conditions Cardio- Type 2 Cancers Asthma Mental Arthritis Injury

vascular diabetes health
health
Tobacco use 4 4 4 4 4
Alcohol misuse 4 4 4+ 4 4
Poor nutrition 4 4 4 ? +
Physical inactivity 4 4 4 4 4 4
Excess weight 4 4 4 + 4 ?
Hypertension 4 + +
Elevated blood lipids 4 +
Chronic stress 4 ? ? ? 4
Lack of social support 4 ? 4
Depression 4 ?+ + + 4 4
Early life 4 4 ? 4 4 ?
(inc. low birth weight)
Low socio-economic status 4 4 4 4 4 4
4 Established risk factor + Association ? Possible risk factor
Adapted from Health Promotion Priorities for Victoria: A discussion paper, page 12[30]
Savings possible from health promotion approaches

The effectiveness of health promotion and prevention has been demonstrated through
numerous national and international reviews[8, 31-37]. There is now good evidence that
comprehensive health promotion and prevention programs are a cost-effective way of
improving the health and well being of the population, thereby minimising the burden of
preventable disease and injury[31-34].
The Australian Return on Investment in Public Health study conducted by Applied Economics
in 2003 outlined significant benefits arising from investment in a range of public health
programs. For example, over the last 30 years the Australian government has spent $176
million on tobacco control campaigns. Along with changes in public health policies, legislation
and tobacco excise, these interventions have resulted in a substantial fall in the prevalence of
smoking and number of cigarettes being consumed[34].
The health benefits have been extensive. In 1998, an estimated 17,400 premature deaths were
averted in Australia due to reduced tobacco consumption. This comprised 6,900 fewer deaths
from cardiovascular disease, 4,000 fewer lung cancer deaths, 3,600 fewer deaths from COPD
and bronchitis, and 2,900 fewer stroke deaths[34].
The reduction in consumption between 1970 and 1998 was linked with a total cost benefit
of $12.3 billion (comprising $9.6 billion in longevity gains, $2.2 billion in improved health
status and $0.5 billion in decreased health care costs). For this reason, tobacco control has
been described as a ‘blue-chip investment’, returning a direct saving of $2 for every dollar
expended, and indirectly as much as $50 per dollar expended[34].
11
Other studies have estimated the cost savings that would be achieved from changes in some of
the behavioural risk factors for chronic disease. For example:
If Western Australia were to achieve a smoking prevalence of 10% by 2010, 1,290

premature deaths would be averted, 20,258 hospital admissions saved, $84 million saved
in heath care costs and $733 million gained in social benefits[38].
Increasing fruit and vegetable consumption by one serve per day would result in direct
health care savings of $180 million annually Australia wide ($18 million in Western
Australia)[39].
Weight loss of 5kg in all Australians who are overweight or obese would reduce the
overall prevalence of overweight and obesity by 15%. The reduction in health care costs
associated with type 2 diabetes alone would be $18.6 million per year ($1.9 million in
Western Australia)[40].
In addition to the financial gains, studies have demonstrated gains in measures of quality of
life, including mental wellbeing, productivity and economic status:
Regular physical activity for older people can improve cardiovascular functioning and
mental health, decrease the risk of falls and regulate blood glucose levels, resulting in a
more active and productive population[31].
Public health nutrition strategies to promote healthy eating and healthy weight have
been shown to result in an improved quality of life for those already overweight or obese,
including improved social interaction and enhanced mental well being[41].
Effective injury prevention strategies can result in major savings to the health care
system in Western Australia. Significant benefits can also be made across the community
in the reduction of loss of wage and household productivity, and loss of quality of life[16].
Future directions
Over the next five years, the promotion of healthier and safer lifestyles in Western Australia
will focus on six priority areas:
Preventing smoking.
Healthy eating.
Physical activity.
Healthy weight.
Low risk alcohol use.
Preventing injury.
As shown in Figure 9, these priority areas are underpinned by a number of key strategic
approaches, priority population groups, intervention types and settings for action.
The key outcomes desired from this approach are a decrease in the morbidity and premature
mortality associated with chronic disease and injury, and a reduction in health inequalities
associated with lifestyle, chronic disease and injury.
12
Figure 9: Future directions for the promotion of healthier and safer lifestyles
in Western Australia
Key strategic approaches

Culturally appropriate Greater targeting of Stronger partnerships to More integrated
approaches for populations at most address the social and and comprehensive
Aboriginal people risk of harm to address other determinants of approaches
health inequities health
A mixture of population Emphasis on creating More systematic early Balance evidence-

level and individual environments that detection of increased based approaches
level approaches support healthy risk of chronic disease with innovation and
lifestyles and reduce the evaluation
risk of injury
Develop programs to Build sustainable A focus on shared Enhanced health

match the conditions resources to support behavioural risk factors promotion for those
and needs of local sustained effort for preventable chronic identified at high risk of
communities disease/injury or with chronic disease
Enhanced prevention
throughout life, starting
early
Types of interventions Priority population groups

Social marketing and mass education Whole of population
Education and skill development Specific life stages
Pregnant women/infants
Environmental supports
Children
Legislation and related policy Young people
Community action/capacity building Adults
Early detection of high risk Older people
Prevention in clinical settings Higher risk groups
Safer products and settings Aboriginal people and communities
Advocacy Lower socioeconomic groups
Sponsorship Rural and remote populations
People at high risk of injury or disease
People with chronic disease
Organisational implementation/ Outcomes

enabling factors
Leadership, policy and strategic planning i morbidity and premature mortality in WA
Partnerships, integration and coordination associated with chronic disease and injury:
Workforce capacity building
Chronic disease: i harmful lifestyle behaviour
Monitoring, surveillance and research
h supportive environments
i lifestyle related disease
Settings for action h early detection of risk
i disease progression
Communities and Institutional care
families Local government Injury: i injury
Schools/child care Hospitals i severity/harm from injury
Sport, recreation and Transport i risky behaviour
leisure Primary health h safety of environments/
Public spaces/ services products
playgrounds i inequalities in health associated with lifestyle,
Workplaces chronic disease and injury
13
Key strategic approaches

Over the next five years, the promotion of healthy and safe lifestyles in the Western Australian
health system will be underpinned by the following:
1. A focus on shared behavioural risk factors for preventable chronic

disease/injury
A number of chronic diseases that share modifiable risk, protective and biomedical factors are
responsible for the highest burden of disease: cardiovascular disease, type 2 diabetes, certain
cancers where risk can be reduced by lifestyle (colorectal, breast, cervical, lung), chronic
respiratory diseases (asthma and COPD) and certain musculoskeletal conditions.
The WA HPSF will target the ‘cluster’ of modifiable risk factors shared by these chronic
conditions and some injuries: smoking, harmful alcohol use, poor diet, physical inactivity and
overweight and obesity.
Mental health related problems, particularly depression, chronic stress and social isolation, are
also important risk factors for both injury and chronic disease.
2. Greater targeting of populations at most risk of harm to address health

inequities
Priority will be given to targeting populations at most risk of chronic disease and injury related
harm:
People living in low socioeconomic circumstances.
Aboriginal people.
People living in rural and remote areas.
Approaches that specifically target the most disadvantaged groups must be supported by
broader population based and environmental interventions. They need to be accessible, set
within a framework of a life course perspective and recognise psychosocial factors.
A number of other groups have special requirements that need to be incorporated into program
development: those from culturally and linguistically diverse backgrounds (particularly
migrants, refugees and humanitarian program entrants), people with physical or intellectual
disabilities, people with mental illness and their children, frail older adults, children living
in out of home care, people living in institutions and those who are socially or geographically
isolated.
3. Stronger partnerships to address the social and other determinants of health

Socioeconomic disadvantage has a significant impact on the risk of disease and likely
effectiveness of health promotion interventions. Efforts to reduce chronic disease and injury
must deal with not only individual factors but also with the broader environmental, social
and economic context in which lifestyle and risk taking behaviours occur. This is particularly
important for populations and groups experiencing social or economic disadvantage.
14
The health sector will take a leadership role in advocating, engaging with and forming
partnerships with other government departments and sectors to address the systematic causes
of disadvantage and narrow the gaps in health between the most and least disadvantaged
groups.
In addition, health promotion programs addressing health behaviours need to[20]:

Target those with the poorest health and who are most affected by social disadvantage.
Identify the barriers and facilitators that impact on the effectiveness of health promotion
interventions and ensure that interventions do not exacerbate inequalities.
Modify interventions and services to empower individuals and strengthen social, family
and community networks to adopt healthier and safer behaviours.
4. More integrated and comprehensive approaches

An integrated approach to health promotion requires a common vision, effective partnerships
and a comprehensive mix of interventions. These need to be implemented across health
agencies, non-government agencies, primary and acute care services, community groups and
agencies outside the health system. Given the clustering of chronic disease and high injury
rates in some sections of the population, there are opportunities to better integrate programs
within common settings.
Mechanisms will be identified and established to improve integration and consistency between:
Statewide campaigns and programs and local or community based interventions.
Interventions targeting those at different stages of risk or development of disease,
including population based and individual level approaches.
Programs and services provided by different agencies and in various settings.
Interventions targeting different risk factors. Opportunities exist to implement multi-
risk factor approaches, such as combined physical activity and nutrition approaches to
prevent weight gain and type 2 diabetes.
Community and school based initiatives.
Lifestyle and mental health promotion programs.
5. A mixture of population level and individual level approaches

Approaches that target populations (such as Aboriginal people or older adults) aim to produce
small changes in risk across the whole community. Greater overall health gains can be made
in the longer-term through small changes to the level of risk experienced by large numbers
of people, than by only focusing on identifying and treating the small number of people with
existing disease.
Prevention efforts need to include action at the population, community and health service
level. Population level approaches create the public policy, community awareness, social norms
and physical environments needed to underpin individual healthy behaviour, whether by well
individuals or those with disease. Intervention through health care interactions can educate
and motivate individuals, whether well, at high risk, or with disease, to adopt healthier
lifestyles.
15
The health system will use approaches that focus both on populations and at risk individuals.
This will ensure that not only is there an immediate impact on health service needs, but also
that rates of chronic disease are significantly reduced in the longer term.
6. Emphasis on creating environments that support healthy lifestyles and

reduce the risk of injury
A key focus will be on the creation of environments and settings that encourage and support
healthier and safer lifestyles, to make ‘healthy’ and ‘safe’ choices the ‘easy choices’, through:
Health policy and legislation to create environments that support healthier and safer
behaviour through regulation and enforcement. Past successful examples include the
banning of tobacco advertising, banning of smoking in work and public places, compulsory
seat belt wearing, setting Australian standards for safety of equipment and taxation
of tobacco and alcohol. Opportunities to develop more effective public policy will be
investigated.
Settings that support healthy behaviour, including homes, schools, health care services,
workplaces, communities, sport and recreation facilities and local government.
Partnerships will be formed with other sectors such as other government agencies, local
government, industry, the media and the sport and recreation sector to address the
environmental determinants of health.
7. Enhanced prevention throughout life, starting early

Prevention efforts need to start before birth through enhanced maternal health, and continue
across the lifespan, focusing on key developmental and transition stages up to and including old
age.
Investment in early childhood can have a far greater impact on long-term health than
interventions later in life. Both population based approaches, which ensure that all children
get a good start, as well as more targeted intensive services to support those with the greatest
needs, will be implemented to address the range of factors that influence families’ ability to
foster appropriate physical and mental health in their children. These should be integrated into
appropriate comprehensive antenatal, post natal and early years development services.
8. Enhanced health promotion for those identified at high risk of or with

chronic disease
There is significant potential for health gain through the adoption of healthy lifestyles by
individuals at increased risk of, or with, chronic disease. In many cases a healthier diet,
physical activity, healthy weight, quitting smoking and less harmful alcohol consumption can
not only reduce the likelihood of disease developing, but also help to delay the progression
of the condition and reducing the number of complications and risk of co-morbidity. Lifestyle
based early intervention has been shown to have a significant impact on health outcomes for
diseases such as type 2 diabetes[42].
Similarly, better integration of injury prevention and management services offers the
opportunity for not only reducing the level of harm resulting from an injury, but also to reduce
the likelihood of a further injury through changing risk behaviours and conditions.
16
The elements of an effective health promotion approach at each of three key stages of disease
development, that is in the well population, among those at high risk and among those with
disease, are illustrated in Appendix 3.
Over the next five years, health services will increase their focus on the promotion of a
healthier and lower risk lifestyle. The Health Networks offer an ideal opportunity to lead
integrated policy and planning across the health system.
9. More systematic early detection of increased risk of chronic disease

The National Service Improvement Frameworks (Appendix 2) emphasise the potential benefits
of early detection of increased risk of chronic disease, pre-disease indicators (such as impaired
glucose metabolism) and chronic disease. This ensures that people are aware of the impact of
lifestyle on their health and disease risk and can implement appropriate changes.
The health system will support more systematic assessment of patients’ lifestyle behaviours
with the aim of facilitating earlier detection and motivating behaviour changed. While not
within its mandate, the WA HPSF supports enhanced screening for family history, pre-disease
indicators and early chronic disease (including cancer and type 2 diabetes).
10. Develop programs to match the conditions and needs of local communities
Interventions are needed at statewide, regional and local level. Health promotion programs will
be developed to meet the needs of local communities and groups. This will require partnerships
at local and statewide level, initiatives to build local capacity and greater engagement of the
community in planning and implementation.
11. Build sustainable resources to support sustained effort

A comprehensive and sustained effort is needed to change lifestyle-related behaviour. While
immediate health gains can result from targeting individuals experiencing or at high risk of
disease or illness, a commitment to sustained resourcing and long-term funding cycles is
needed to achieve the substantial longer-term gains from targeting the whole population and
reducing future disease and injury rates. In addition, funding for health promotion needs to be
integrated into business planning at state, regional and health service level.
12. Balance evidence-based approaches with innovation and evaluation

Priorities and interventions will be based on the best available research about effectiveness.
There are considerable gaps in the evidence base for some areas, particularly in relation to
effective approaches for Aboriginal people and other hard to reach groups, and the prevention
of obesity and some types of injuries. The evidence base for policy and program development
will be strengthened through continued research and evaluation, and better dissemination of
findings. The use of innovative approaches will be supported where these are based on sound
theory and professional expertise, fully evaluated and likely to extend the evidence base.
d
Linking to the Lifescripts program being implemented by general practitioners.
17
13. Culturally appropriate approaches for Aboriginal people

Addressing the considerable inequalities in health among Aboriginal people in Western
Australia will be a priority for the next five years. Appropriate interventions targeting
Aboriginal people are needed for all of the strategic directions outlined in this WA HPSF.
The factors that determine the risk of harmful lifestyle practices and risk of injury
in Aboriginal people are embedded into the broader cultural, social, economic and
environmental history and conditions, including the impact of colonisation, family
dispersal and the disadvantaged socioeconomic circumstances under which many live.
Policy and program planning and development to address chronic disease and injury
among Aboriginal people should reflect a holistic perspective that encompasses not
only physical wellbeing, but also the social, emotional, spiritual and cultural wellbeing
of the whole community. These need to be supported by partnerships to engage
Aboriginal people and communities, and programs to address early childhood health and
development, and other determinants of health such as education and employment.
Approaches will need to include a focus on self-determination, cultural security,
community needs and greater collaboration and partnerships at all levels.
The WA HPSF supports the principles and guidelines outlined in the WA Aboriginal
Cultural Respect Implementation Framework.
The WA HPSF also endorses the priorities for action outlined in the Strong Spirit Strong
Mind: Western Australian Aboriginal Alcohol and Other Drugs Plan 2005–2009 and the
Western Australian Aboriginal and Torres Strait Islander Health Promotion Action Plan
2005-2008. The action plan identifies the key action areas:
Develop strong partnerships between Aboriginal community organisations and
mainstream agencies and increase the responsiveness of mainstream services to
the needs of Aboriginal people.
Build capacity for health promotion targeting Aboriginal people.
Promote the development of healthier workplace and community policies.
Develop and evaluate tobacco and alcohol control, nutrition and physical activity
initiatives.
Ensure environments support healthier lifestyles.
Evaluate all Aboriginal programs to build the evidence base.
Advocate for increased resource allocation and integration of prevention
approaches across government and non-government sectors.
The WA HPSF recognises the similarities and differences among Aboriginal cultures and
circumstances (including geographical location) and the importance of developing local
ownership and capacity within communities to plan and implement interventions.
18
Achieving a healthier and safer lifestyle

The Western Australian Health Promotion Strategic Framework 2007-2011 identifies six priority
areas for health promotion action:
Preventing smoking
Effectively monitor and enforce legislative controls on the sale, supply, advertising and
promotion of tobacco.
Increase the urgency of stopping smoking and of protecting others from exposure to
second-hand smoke.
Reduce exposure to second-hand smoke.
Improve access to smoking cessation support across the continuum of health care and the
community.
Discourage uptake of smoking by young people.
Broader community engagement in tobacco control interventions and issues.
More innovative programs to address smoking among Aboriginal people and other high-
risk groups.
Healthy eating
More equitable access to affordable, nutritious and safe food.
Increase appropriate breastfeeding of infants and introduction of complementary foods.
Increase community awareness of the recommended types and amounts of foods and
drinks to consume and the benefits of healthy eating.
Increase knowledge and skills to adopt a healthy diet.
Develop settings and environments that support healthy nutrition.
Increase risk assessment, early identification, brief intervention and referral to nutrition
services.
Physical activity
Increase community awareness of the need for an active lifestyle and appropriate levels
of physical activity to promote good health.
Create physical environments that provide opportunities for increased physical activity.
Develop organisational environments/settings that provide opportunities for increased
physical activity.
More culturally relevant community based physical activity programs and services for
priority and high risk populations and groups.
Increase risk assessment, early identification, brief intervention and referral to
community physical activity services and programs.
19
Healthy weight
Integrate nutrition and physical activity approaches.
Increase community awareness of healthy weight, the benefits of healthy weight, the
health risks associated with overweight and obesity and how to prevent weight gain.
Increase parents’ ability to establish healthy eating and physical activity behaviours
among children early in life.
Build community engagement, capacity and motivation for local action to address
environments and lifestyles that support overweight and obesity.
Increase risk assessment, early identification and brief intervention to prevent weight
gain among those identified at increased risk of chronic disease.
Early reversal of small unhealthy weight gains.
Work with sectors outside health to develop policy and programs addressing the
determinants of obesity.
Low risk alcohol use

Appropriately regulate the physical availability of alcohol.
Reduce community acceptance of drunkenness and associated behaviour.
Increase the responsible service, marketing and promotion of alcohol.
Increase risk assessment, early identification and brief intervention for those consuming
alcohol at potentially harmful levels.
Advocate for alcohol pricing that limits harmful alcohol consumption.
Preventing injury
Reduce falls and related harm in older people.
Reduce falls, accidental poisoning and burns and scalds in children.
Reduce road trauma, particularly among young males.
Reduce drowning and near drowning in children and adults.
Contribute to reducing the harm from violence and assault.
Reduce injuries in males from falls and DIY injuries.
Enabling and implementation actions

A number of system level and organisational changes and actions are needed to underpin the
implementation of the key strategic directions outlined in the WA HPSF:
Leadership, policy and strategic planning.
Partnerships, coordination and integration.
Workforce capacity building.
Monitoring, surveillance and research.
Implementation actions specific to each priority area are identified at the end of each priority
area section. Actions that apply to all the priority areas are discussed in a later section.
20
Preventing smoking
Despite success in reducing the overall prevalence of smoking over the last three decades,
tobacco still remains the leading cause of preventable disease and death in Western
Australia[43]. Tobacco causes a range of chronic and disabling conditions, including
cardiovascular disease, lung disease and cancer. There is no safe level of smoking. Even light
smokers who only consume one to four cigarettes per day triple their long-term risk of dying of
cardiovascular disease or lung cancer[44]. In addition, exposure to second-hand smoke causes a
number of diseases in non-smokers, newborns and children[45-47].
Smoking prevalence reflects a strong social gradient, increasing as socioeconomic disadvantage

increases[48]. The higher prevalence is due to higher commencement rates rather than
differences in cessation rates[49].
The reduction in the prevalence of smoking has been achieved using a mixture of individual
and population wide approaches designed to reduce or delay tobacco uptake, increase smoking
cessation and reduce exposure to second-hand smoke. Western Australia has taken a lead role
in tobacco control, implementing comprehensive media campaigns; introducing legislation
banning tobacco advertising, restricting point of sale promotion, limiting access for juveniles,
and banning smokeless tobacco; establishing Healthway to phase out tobacco sponsorship of
sporting and cultural events; and implementing legislation banning smoking in enclosed public
places, workplaces and defined transport facilities.
Despite this there are considerable challenges in this area. Certain subgroups continue to
have a very high prevalence of smoking. Despite the legislation, there is damaging exposure
to tobacco smoke in a number of settings, particularly institutional settings, al fresco dining
areas, homes and cars. Continued monitoring and restrictions on tobacco marketing, packaging
and products are needed to counter tobacco industry claims and new product marketing.
Smoking:
In Western Australia, 13% of those aged 16 years and over smoke every day . The
[22]
prevalence of smoking in Western Australia has halved in the last two decades[43, 50].
Groups with high levels of smoking include:

Low socioeconomic groups .
[22, 52]
Aboriginal adults (one in two smoke daily)[52].

People living in rural and remote areas .
[53]
Those who have a mental illness .

[5, 54]
Adult and juvenile prisoners .

[55]
Pregnant women , particularly Aboriginal women .

[45] [56]
More than 90% of smokers begin as teenagers . In 2005, 32% of Western Australian school
[57]
students aged 12 to 17 years had smoked at least part of a cigarette in their lifetime[59].
In 2005, 38% of Western Australian school students aged 12 to 17 years reported living with
someone else who smokes[59].
Each year in Western Australia, tobacco smoking is responsible for around 1500 deaths,
over 14,000 hospital admissions and more than 84,000 bed days per year, equating to
approximately $60 million in hospitalisation costs[60]. In 1998/99 the total societal costs of
smoking were estimated at $1.6 billion[38].
21
Strategic directions
There is good evidence that long-term investment in tobacco control programs can significantly
reduce the use of tobacco and save lives where programs are comprehensive, evidence-based
and appropriately funded[61-64]. Research also shows that when efforts are not maintained and
funding is inadequate, positive trends will reverse.
Outcomes desired:
Reduce the prevalence of tobacco use.
Reduce exposure to tobacco products.
Over the next 5 years the WA health system will focus on:
Motivating and supporting cessation by adults.
Preventing uptake by children and young people.
Reducing the potential for exposure to second-hand smoke.
Target populations will be:

Whole of population, with added focus on groups with higher risk of tobacco-related harm:
Aboriginal people.
Rural and remote populations.
Other groups such as those who have a mental illness, pregnant women and new parents,
the prison population and those at high risk of or with chronic disease.
1. Effectively monitor and enforce legislative controls on the sale, supply, advertising and
promotion of tobacco.
2. Increase the urgency of stopping smoking and of protecting others from exposure to second-
hand smoke.
3. Reduce exposure to second-hand smoke.
4. Improve access to smoking cessation support across the continuum of health care and the
community.
5. Discourage uptake of smoking by young people.
6. Broader community engagement in tobacco control interventions and issues.
7. More innovative programs to address smoking among Aboriginal people and other high-risk
groups.
22
1. Effectively monitor and enforce legislative controls on the sale, supply,

advertising and promotion of tobacco
Regulation of tobacco has been a key component of the successful tobacco control approaches
in Western Australia. Comprehensive restrictions on cigarette advertising and promotion[65],
increasing the price of tobacco through excise[65], mandating the use of health warnings
on packaging[34], regulation of tobacco products[66] and enforcement of bans on the sale of
cigarettes to minors[57] have all been shown to be effective.
Actions
Continue to monitor, enforce and review the Western Australian Tobacco Products
Control Act 2006 to ensure that the legislation remains robust and effective.
Advocate for tobacco excise levels that discourage smoking and for continued effective
health warnings on cigarette packaging.
Ensure that the community and industry are aware of the legislation and its implications.
2. Increase the urgency of stopping smoking and of protecting others from

exposure to second-hand smoke
Comprehensive approaches that combine hard hitting long-term mass media campaigns with
other targeted tobacco control interventions can achieve real reductions in the prevalence of
smoking for both adolescents and adults[65, 67-71], particularly where funding and programs are
sustained. A comprehensive social marketing approach is needed to increase the salience of
the effects of smoking and exposure to second-hand smoke, personalise these health risks and
motivate smokers to quit.
High profile campaigns that target adults also have the potential to reduce smoking in children
through changes in perceived social norms and impact on parental smoking[72, 73]. In Australia,
adolescents have shown positive responses to adult-focused campaigns[74].
Actions
Implement effective, long-term comprehensive mass media campaigns and programs
targeting adults and young people.
Develop and implement culturally appropriate campaigns, programs, resources and

publications for Aboriginal people and other high-risk groups.
Provide local support for national and statewide mass media campaigns and programs.
3. Reduce exposure to second-hand smoke

Total smoking bans and restrictions that prevent exposure to second-hand smoke in the
workplace can also reduce daily tobacco consumption and the success of quit attempts[69, 75].
The Tobacco Products Control Act 2006 and the Occupational Safety and Health Regulations
1996 prohibit smoking in a range of enclosed public spaces, workplaces and transport facilities.
Despite this, there is still significant exposure to tobacco smoke in some workplaces, such as
prisons, and homes and cars.
23
Actions
Monitor, enforce and review the legislation and regulations limiting the use of tobacco in
indoor areas.
Expand smoke free workplaces, institutions, public outdoor and alfresco entertainment
areas.
Develop and implement a Smoke Free WA Health policy across all public health services
and facilities.
Discourage smoking in private places such as the home and car.
4. Improve access to smoking cessation support across the continuum of

health care and the community
It is common for people to need multiple attempts to quit before finally becoming a non-
smoker[72]. Only seven per cent of smokers achieve long-term success quitting on their own
without support[76]. A number of smoking cessation interventions are effective at improving
rates of quitting: pharmacotherapies (nicotine replacement therapy[77] and buproprion[78]), brief
interventions by trained health professionals[79-82], intensive individual or group counselling[77, 83]
and telephone counselling (particularly when promoted in conjunction with other
approaches[84-86]).
Actions
Build the capacity of health professionals in hospitals and primary health (such as general
practitioners and other doctors, nurses, dentists, pharmacists, Aboriginal health workers
and community health workers) to identify patient smoking history and behaviour and
provide advice on quitting.
Boost health professionals’ knowledge of tobacco control practice, priorities, resources

and referral opportunities.
Increase access to a range of affordable cessation programs, including brief

intervention, intensive individual counselling and supportive group sessions, telephone
counselling (Quitline) and related support materials, website/on line programs and
pharmacotherapies.
Develop cessation programs for specific population groups and/or integrate these into
other services (particularly for Aboriginal people, those with a mental illness, pregnant
women and new parents, and those at high risk of or with chronic disease).
Incorporate smoking cessation advice into chronic disease self-management programs.
5. Discourage uptake of smoking by young people

Preventing the uptake of smoking is a critical component of effective tobacco control.
Approaches that include comprehensive school-based tobacco interventions (comprising smoke
free policies, curriculum, teacher training and parental involvement) and linkage with local
and statewide campaigns have the best chance of reducing or delaying the uptake of smoking
among young people[61].
24
Actions
Work with education authorities to encourage and support schools to implement tobacco
control policy, education and smoking behaviour management initiatives.
Provide local support for national and statewide mass media campaigns and programs
targeting young people.
6. Broader community engagement in tobacco control interventions and issues

Local government, schools, local community networks and groups, regional health promotion
agencies, Aboriginal health organisations, culturally and linguistically diverse groups and
workplaces have the potential to develop and implement tobacco control policy and programs
that support statewide regulatory and education initiatives but are tailored to local groups and
conditions.
Actions
Implement initiatives that build on the high level of community support for tobacco
control measures and encourage and facilitate broader community engagement in
tobacco control interventions and issues.
7. More innovative programs to address smoking among Aboriginal people and

other high risk groups
Despite the continuing high levels of smoking and related harm among Aboriginal people, there
is limited evidence about the effectiveness of tobacco control interventions targeting this
group.
Actions
Develop and implement innovative and culturally appropriate tobacco control programs
for Aboriginal people in partnership with local Aboriginal communities and agencies.
Implement smoking programs in Western Australian mental health facilities, including

bans on smoking, staff training, patient education and smoking cessation support.
Develop policy and initiatives targeting smoking among other priority groups.
Enabling and implementation issues specific to tobacco

Form partnerships with, and increase the capacity of, sectors outside health, such as
local government, education, corrective services, other government agencies, workplaces
and family support and parenting services. These agencies have the potential to extend
the reach and impact of tobacco control initiatives.
Improve the availability of information for policy, evaluation and program development:
Improve monitoring of smoking among priority population groups (particularly
Aboriginal people).
Invest in developing a sound evidence base for effective Aboriginal tobacco control
and interventions.
25
Healthy eating
Healthy eating is essential for good health at all ages across the lifespan. A life course
approach starts with maternal health and prenatal nutrition and breastfeeding for at least
six months. It continues with the development of healthy eating habits in early childhood,
and their continuation into adolescence, adulthood and old age. The Australian Dietary
Guidelines[87, 88] and Nutrient Reference Values[89] provide recommendation for a healthy diet
across the lifespan, for pregnant women, infants, children and adults.
Poor nutrition is a risk factor for a number of chronic diseases, including but not limited to
type 2 diabetes, cardiovascular disease, stroke, cancer and some musculoskeletal disorders[87].
Diets that are high in saturated fat, salt and sugar and low in plant foods are associated with
high blood cholesterol, hypertension and obesity. Combined, these conditions account for
10% of the total burden of disease in Western Australia[90]. There is good evidence that diets
high in fruit, vegetables and legumes can substantially reduce the risk of a number of chronic
conditions (particularly heart disease, certain cancer, stroke, type 2 diabetes and some eye
disease)[87].
While there is some evidence that the Australian diet is improving, many people do not eat the
recommended levels of many key dietary items, including vegetables and fruit[22]. Energy and
sugar intake have increased among adults and children, mainly due to increased consumption of
sweetened and soft drinks, fast food and confectionary. Total fat consumption has decreased
slightly among adults. Vegetable consumption by Western Australian adults has increased over
the last 10 years, but that of children has decreased[91].
Action is needed to address the worsening trends in overweight and obesity in children and
adults, the increasing rates of type 2 diabetes and the very high rates of nutrition-related
chronic disease among some sectors of the population, particularly Aboriginal people and those
living in low socioeconomic circumstances. The increase in overweight and obesity is linked to
increased energy intake[92] and the increased energy densitye of foods.
Healthy eating
In 2006, approximately half of Western Australian adults were not eating the
recommended two serves of fruit each day, while more than four in five adults (84%) were
not eating the recommended daily amount of vegetables[22].
In Western Australia in 2006, 7% of 4-11 year olds and over three-quarters (77%) of 12-17
year olds were not eating the recommended daily intake of fruit[22].
Two thirds (63%) of Aboriginal people eat less than four serves of vegetables daily and 59%
eat less than two serves of fruit a day[52].
At six months, 46% of mothers are breastfeeding their infant, with less than one per cent
exclusively breastfeeding[23].
e
Energy density is the energy content per unit weight of foods, drinks or meals. Fat and sugar contribute
positively to energy density, whilst water and fibre are negatively related.
26
Healthy eating (cont.)

In 2006, 88% of Western Australian children ate fast food, with 11% eating fast food two or
more times a week[22].
The estimated total national health care costs associated with colorectal, breast, lung and
prostate cancers due to low vegetable intake is approximately $59 million per year, and
for breast and lung cancers due to low fruit intake is $29 million annually[39].
Recent reviews and national[93] and state[94] strategies have identified key areas in nutrition that
may offer the most significant population health gains. These are attention to early nutrition,
increasing the proportion of plant foods in our diets and appropriate energy intake from low
energy density, nutritious foods and drinks.
The World Health Organization[95] recommends a comprehensive approach to nutrition

promotion to prevent chronic disease, using multiple strategies that address food supply, food
access and food choice. A mixture of broad population based approaches, interventions for
specific populations and targeted individual approaches is needed. Government leadership and
engagement of a broad range of partners is essential for sustained progress.
Outcomes desired:
Increased consumption of a diet consistent with the Australian Dietary Guidelines.
Balancing energy intake with physiological need and physical activity.
Increasing fruit and vegetable intake.
Optimising antenatal, maternal, infant and child nutrition.

Whole of population at intervention points across the life course (infants, children and
young people, pregnant women, new mothers, adults and older people).
Aboriginal people.
Other groups such as those with a physical disability, mental illness, the prison population,
those at high risk of or with chronic disease, migrants, refugees and humanitarian program
entrants.
Those at high risk of or with chronic disease.
27
1. More equitable access to affordable, nutritious and safe food.
2. Increase appropriate breastfeeding of infants and introduction of complementary foods.
3. Increase community awareness of the recommended types and amounts of foods and
drinks to consume and the benefits of healthy eating.
4. Increase knowledge and skills to adopt a healthy diet.
5. Develop settings and environments that support healthy nutrition.
6. Increase risk assessment, early identification, brief intervention and referral to nutrition
services.
1. More equitable access to affordable, nutritious and safe food

Access to affordable, culturally appropriate, nutritious food is determined by policies and
fiscal issues at various levels including government, grower, producer, distributor, retailer,
institutional management and household gatekeeper.
Actions
Advocate for and contribute to the development and review of regulations and legislation
related to food composition, labelling, advertising and marketing.
Improve ease, equity and sustainability of access to affordable, good quality, nutritious
and safe food, particularly in remote areas and for vulnerable groups, through
partnerships with industry, local communities and other stakeholders.
Improve healthy food supply in settings such as the food service and hospitality industry,
health care facilities and other institutions, workplaces, childcare and schools and out-
of-school care.
Develop and implement a food and nutrition policy for WA Health services and facilities.
2. Increase appropriate breastfeeding of infants and introduction of

complementary foods
Exclusive breastfeeding for 6 months and appropriate introduction of complementary foods
contribute to optimal physical growth and mental development[23]. Effective interventions
include one-to-one education and small group antenatal programs that engage expectant
parents and extended family; postnatal home visits and/or individual sessions with health
professionals; peer support; and hospital practices such as rooming-in, early skin-to-skin
contact and appropriate hospital discharge[96]. Peer support is particularly effective for low
income, ethnic minorities or vulnerable groups[97].
Actions
Promote and support exclusive breastfeeding for six months and continued breastfeeding
with appropriate complementary foods through community programs targeting expectant
and new mothers, their partners and extended families.
Create supportive environments for breastfeeding through policies and procedures in

a range of settings including hospitals, workplaces, community health services and
community settings.
28
3. Increase community awareness of the recommended types and amounts of

foods and drinks to consume and the benefits of healthy eating
Accessible, consistent and evidence-based information is needed about the types and amounts
of foods, particularly fruit and vegetables, to eat for good health to counter community
uncertainty created by misinformation and the changing nature of the food supply[98]. Sustained
social marketing campaigns (including mass media and point-of-sale promotion) have been
effective in increasing knowledge, attitudes and behaviour in relation to reducing fat intake[99]
and increasing fruit and vegetable consumption[100].
Actions
Implement sustained mass media campaigns and programs to increase awareness of the
recommended intakes of fruit and vegetables and of recommendations related to healthy
body weight (such as energy density, portion size and child nutrition).
Increase access to culturally appropriate information about nutrition requirements and

healthy food and drink choices throughout the life course, including childhood.
Provide targeted education about the links between poor diet and disease (such as type 2
diabetes and cardiovascular disease).
4. Increase knowledge and skills to adopt a healthy diet

Healthy food selection, preparation and budgeting skills are the basis for choosing a healthy
diet, but have been devalued in recent generations. Young people and families, those with
limited disposable income or limited formal education, and those from different cultural
backgrounds are the least likely to have these skills[101]. Community-based and peer led
interventions and programs are most effective in supporting these groups to develop the
appropriate knowledge and skills to adopt a healthy diet[102].
Actions
Implement community based nutrition information and skills development programs
(including food purchasing, budgeting and preparation) targeting low-income families,
Aboriginal families and groups, migrants, refugees and humanitarian program entrants.
5. Develop settings and environments that support healthy nutrition

Comprehensive nutrition promotion programs (including policy, food access and education)
have been shown to be effective in supporting healthy food choices in a number of
settings[103-105]. This approach ensures that interventions are culturally appropriate and address
local food supply and choice factors. It also offers opportunities for integrated multi-risk factor
interventions (such as combined nutrition and physical activity programs to address overweight
and obesity).
29
Actions
Develop and implement comprehensive nutrition programs that address policies, supply
and education in the following settings:
health care facilities
workplaces
schools and out-of-school care, as part of a comprehensive health promoting schools
approach
childcare
defined communities, especially remote communities, Aboriginal people and culturally
and linguistically diverse groups
sport, recreation and other settings where food is supplied.
6. Increase risk assessment, early identification, brief intervention and

referral to nutrition services
There is evidence supporting the effectiveness of brief intervention and dietary counselling
and follow up by health professionals[106]. Inclusion of nutrition in disease self-management
programs can improve the management of chronic disease precursors (for example, high blood
pressure, glucose intolerance, elevated blood lipids and metabolic syndrome) and delay disease
progression[42, 106-111].
Actions
Motivate and support more systematic nutritional assessment, early identification of risk
and brief nutritional intervention for pregnant women and those at high-risk of or with
chronic disease (particularly type 2 diabetes, cardiovascular disease, cancer, asthma and
musculoskeletal conditions) as part of the core business of all health services.
Support referral to appropriate community nutrition services and programs tailored to

individuals, groups and communities.
Build capacity of health professionals, particularly the primary care sector, to undertake
nutrition interventions by developing appropriate screening tools, educational support
materials and referral information about locally available nutrition and lifestyle change
services and professionals.
Incorporate nutrition into chronic disease and self-management programs.
Enabling and implementation issues specific to promoting healthy eating

Health sector leadership, partnerships and coordination to influence food supply and
marketing policies including advertising and sponsorships, working with:
national, state and local governments

food production and distribution industry
food service and hospitality industry.
More joint initiatives with physical activity and obesity programs and better linkages with
other lifestyle based interventions.
Invest in monitoring nutrition-related attitudes and behaviours, including energy intake,

among children, adolescents and adults.
30
Physical activity
Appropriate levels of physical activity have significant health benefits, both mental and
physical, for all ages across the life course. Lack of physical activity is linked to increased
risk of illness, disability and premature death associated with chronic diseases (particularly
cardiovascular disease, type 2 diabetes and colon and breast cancer). Physical inactivity is a
major factor in the epidemic of overweight and obesity[112].
Regular moderate physical activity helps to prevent and manage a number of biomedical risk
factors for chronic disease, including hypertension, elevated blood lipids, insulin sensitivity,
impaired glucose tolerance and unhealthy body weight. It can reduce the risk of cardiovascular
disease, prevent or delay the onset of type 2 diabetes and can reduce the risk of some forms of
cancer[113-114]. Physical activity promotes bone and muscle strength, provides protection against
osteoporosis, reduces the risk of hip fractures through falls; reduces the risk and consequences
of arthritis; and assists people with chronic, disabling conditions to perform activities of daily
living. It also has mental health benefits such as the reduction of depression, low self-esteem,
anxiety, stress and poor self-concept[115-118].
The national Physical Activity Guidelines for Australians[119] and National Physical Activity
Guidelines for Children and Young People[120] make recommendations for the level of activity
needed each day for good health. They encourage people to think of movement as an
opportunity, not an inconvenience and to be active every day in as many ways as possiblef.
People with a physical disability can also benefit from physical activity, but the amount and
type will vary with individual circumstances[121].
Physical inactivity is responsible for five per cent of the burden of disease and injury in Western
Australia[90] Most Australian adults and children do not do enough physical activity for good
health, and levels of activity have been decreasing over the last few years[122].
Physical activity
In 2006 in Western Australia:
Only 45% of adults aged 16 years and over reported sufficient physical activity for health
benefit[22,119].
76% of primary school students aged 5-12 years reported insufficient physical
activity[22,120].
Children aged 15 years and under spent an average of 11 hours on screen-based activities
per week, and 95% spent more than the recommended two hours per day on these
activities[22].
In 2005 in Western Australia, only 50% of children aged 5-16 years with a disability performed
sufficient physical activity to meet Australian guidelines[121].
In 2003 in Western Australia:
Approximately 50% of school students aged 7-16 years reported no active transport to
school[123].
High school students aged 13-16 years were less active outside school hours than primary
school students aged 7-12 years[123].
Based on national figures, the direct health care cost of physical inactivity for Western
Australia is estimated to be approximately $36 million per year[112].
f
The national Physical Activity Guidelines for Australians and National Physical Activity Guidelines for
Children and Young People recommend: adults undertake 30 minutes or more of moderate-intensity activity
on most, or preferably all, days; children and young people should participate in at least 60 minutes (and up
to several hours) of moderate to vigorous intensity physical activity every day.
31
The greatest population gains in relation to physical activity will be achieved by increasing
levels of activity in people who are inactive and insufficiently active. People who are physically
active at an early age, especially through adolescence, are most likely to be active adults[32].
A comprehensive multi-faceted approach that engages key stakeholders and combines whole
of community approaches, supportive environments and individual behaviour approaches is
needed to reduce inactive lifestyles[32, 33, 124]. The across government Premier’s Physical Activity
Taskforce’s Strategic Direction Report[125] provides guidance for cross-sectoral strategies to
increase the physical activity levels of Western Australians. Be Active Australia[126] provides a
framework for defining Western Australian health sector action to promote physical activity.
Outcomes desired:
Increased population levels of physical activity.
Promoting physical and social environments that support physical activity.
Improving access to affordable, socially and culturally relevant options for physical
activity.
Increasing participation in physical activity to meet or exceed recommendations.

Whole of population, at intervention points across the life course (infants, children and
young people, pregnant women and mothers of young children, adults, older people).
Aboriginal people.
Other groups such as those with a physical disability, mental illness, the prison
population, migrants, refugees and humanitarian program entrants.
Those at high risk of or with chronic disease.
1. Increase community awareness of the need for an active lifestyle and appropriate levels
of physical activity to promote good health.
2. Create physical environments that provide opportunities for increased physical activity.
3. Develop organisational environments/settings that provide opportunities for increased
physical activity.
4. More culturally relevant community based physical activity programs and services for
priority and high risk populations and groups.
5. Increase risk assessment, early identification, brief intervention and referral to
community physical activity services and programs.
32
1. Increase community awareness of the need for an active lifestyle and

appropriate levels of physical activity to promote good health
Community awareness of the level of physical activity needed for a health benefit is low[122].
People need access to physical activity information that is evidence-based, easily understood,
consistent, reviewed regularly and widely available. A range of media support services can
be used (social marketing, web sites, public relations and community education). Information
should be appropriate for, and reflect, different cultures and population groups. Large scale,
high intensity, community-wide campaigns with sustained high visibility can be an effective
component of broad population-based approaches to increase physical activity[33, 127].
Actions
Implement whole of community campaigns and programs, including mass media, linked to
other activities (such as self-help groups, counselling, settings-related activities and risk
factor screening).
Increase access to culturally appropriate information about optimal physical activity

levels throughout the life course.
Provide targeted education about the links between physical inactivity and risk of harm
or development of disease for those at risk of or with particular conditions (particularly
cardiovascular conditions, type 2 diabetes, asthma, cancer and musculoskeletal
conditions).
2. Create physical environments that provide opportunities for increased

physical activity
The impact of physical environments on levels of physical activity is only now being studied
extensively. There is a need for more long-term rigorous research. Current research indicates
that environmental attributes, functionality (street or urban design, traffic and the presence of
paths), aesthetics (trees and views), safety and destinations (shops, facilities and transport) in
neighborhoods all impact on physical activity[128]. Health benefits have been demonstrated from
active transport and active commuting policies and programs[113].
Actions
Advocate and form partnerships to influence urban design, planning, transport-related
activities and recreational facilities (such as bike paths, pools, street design and safety
measures).
3. Develop organisational environments and settings that provide

opportunities for increased physical activity, particularly for high risk
groups
Organisational environments such as worksites and schools offer settings than can reach large
numbers of people from diverse backgrounds and provide opportunities for integrating physical
activity with other health issues (such as sun protection and healthy eating).
The evidence around the long-term impact of workplace physical activity interventions is
mixed, with some approaches showing promise[33, 124, 129]. Reviews of school-based interventions
support the Health Promoting Schools approach for action in the school setting[130], including
curriculum, policy and environmental strategies. Interventions through schools that seek to
33
decrease TV viewing time also show some promise. There are few evaluations of physical
activity-oriented interventions with very young children[32], although outdoor play and activity
with a parent or carer can contribute to physical, social and emotional
development[32, 116, 130-132].
Actions
Create settings that provide multi-faceted approaches to increasing physical activity,
including social and environmental supports, policies, education and reminders to be
active, in:
workplaces
schools and out-of-school care
childcare
defined communities, especially remote communities, Aboriginal people and culturally
and linguistically diverse groups
sport and recreational events.
4. More culturally relevant community-based physical activity programs and

services for priority and high risk populations and groups
A number of groups report lower participation in physical activity than the general population:
those with lower levels of education, Aboriginal people, those born overseas or who speak a
language other than English at home, and those with a disability[133].
While there is also little in the way of evidence to inform specific program recommendations
for these groups, there are a number of programs operating throughout Australia, which
address physical inactivity either directly (sport or traditional Aboriginal activities) or indirectly
(such as healthy weight programs)[134, 135]. Programs and services for these groups need to
recognise diversity, involve partnerships with community and key groups and ensure equitable
access (which may require innovative solutions in rural and remote areas)[126].
Actions
Implement targeted physical activity programs (for example, community walking/
exercise groups, transport/walk to work initiatives and community events) for:
Aboriginal families
low income families and groups
older people (to prevent falls and osteoporosis)
people at risk of or with chronic disease, particularly men
families with children at risk of overweight
people with disabilities.
Increase access to community-based physical activity programs and opportunities for
Aboriginal people, and better evaluation to improve the evidence base.
34
5. Increase risk assessment, early identification, brief intervention and

referral to community physical activity services and programs
Brief interventions delivered to patients in primary health care settings can achieve short-
term (at least six month) increases in physical activity, particularly among those with health
problems[136]. Longer-term success can be achieved with the involvement of other practitioners
such as exercise scientists and health educators, and through the use of multi-faceted
programs tailored to the needs and circumstances of participants (particularly older people[137]
and adolescents)[130]. There is evidence that the onset of type 2 diabetes can be prevented or
delayed with increased activity and other improvements in lifestyle[79].
Actions
Motivate and support more systematic assessment of physical activity levels, early
identification of risk and brief physical activity intervention for those at high risk of falls
and fractures and at high risk of or with chronic disease (particularly type 2 diabetes,
cardiovascular disease, asthma, cancer and musculoskeletal conditions).
Support referral to appropriate community services (tailored individual/group programs

g
or community physical activity programs).
Build capacity of health professionals, particularly the primary care sector, to undertake
brief physical activity interventions by developing appropriate screening tools,
educational support materials and referral information about locally available physical
activity and lifestyle change services and professionals.
Incorporate physical activity advice into chronic disease and self-management programs.
Enabling and implementation issues specific to promoting physical activity

Work in partnership with government, non-government and other agencies (through the
Premier’s Physical Activity Taskforce at state level, and through local agencies such as
local government at community level) to influence environments and access to services
that provide opportunities for increased physical activity, particularly for disadvantaged
populations.
More joint initiatives with nutrition and obesity programs and better linkages with other
lifestyle based interventions.
Support efforts to improve physical activity measurement and to collect data on
populations with special needs.
Invest in monitoring physical activity and key attitudes among children, adolescents and
adults.
g
As part of chronic disease management programs or support programs (for example, phone counselling).
35
Healthy weight
Whilst a small proportion of individuals experience health problems related to inadequate
growth or underweight, the overwhelming concern for the health system and society at large
is the growing epidemic of overweight and obesity. The last two decades have seen significant
increases in the rates of overweight and obesity among adults[138-140] and children[123].
Unhealthy body weight results from a prolonged imbalance of energy intake and energy
expenditure through growth and physical activity. While there are genetic differences that
influence an individual’s susceptibility to unhealthy weight gain, there are many social,
cultural, environmental and economic factors that impact on weight, eating and physical
activity.
Over the last three decades there have been profound changes in lifestyle due to factors
such as urban design, reliance on cars, occupational roles, technology, marketing and access
to food. These widespread changes have led to decreased energy expenditure and increased
energy intake, with consequent population weight gain[92].
In addition, there is evidence that increased consumption of soft drinks and snack foods,
and more inactive behaviour (through excessive TV watching and computer use[141]) are key
contributors to increasing levels of obesity in children.
Overweight and obesity increase the risk of a range of serious conditions including type 2
diabetes, heart disease, asthma, gallbladder disease, depression and social isolation, stroke,
osteoarthritis, back problems, infertility and some cancers. Rising childhood obesity rates
are of particular concern given the evidence of the links between childhood obesity, physical
inactivity and eating behaviour and obesity in adulthood, as well as long-term chronic
conditions such as some cancers, type 2 diabetes and cardiovascular disease[3].
The Healthy Weight for Adults and Older Australians[142] and Healthy Weight 2008: The
National Agenda for Children and Young People and Their Families[143] recommend that
population based approaches to the prevention of overweight and obesity focus on promoting
healthy weight gain during pregnancy, promoting healthy growth of children, preventing weight
gain in adults, and better management of early risk and weight.
Overweight and obesity

In 2006, 60% of Western Australian adults males (aged over 16 years) and 43% of adult
females of this age were overweight or obese[22]. These rates have doubled over the last
two decades[138-140].
Between 1985 and 2003, overweight and obesity more than doubled in Western Australian
male school children aged 7-15 years (9% to 23%) and almost tripled in female school
children of the same age (11% to 30%)[123].
Western Australian children aged 15 years and under who eat fast food more than twice a
week are four times more likely to be overweight or obese than others[22].
36
Overweight and obesity (cont.)

Certain demographic groups have a higher prevalence of overweight and/or obesity :
[22, 144]
45 to 64 year olds.
People in the most disadvantaged socioeconomic groups.
People in rural and remote areas.
People with a disability.
Rates of obesity among Aboriginal people are greater than for non-Aboriginal people.
Rates for Aboriginal women are almost double that of non-Aboriginal women[145].
Should obesity trends continue to increase at the current rate, the number of obese
Australians could more than double to 7.2 million by 2025 (29% of the population)[34].
Based on national studies, it is estimated that obesity costs health services in Western
Australia $88 million per year. The total economic cost of obesity in Australia in 2005 was
estimated to be $21 billion[34].
There is considerable overlap between the issues presented in this section and the strategic
directions outlined in the Healthy Eating and Physical Activity sections. However, approaches
to prevent overweight and obesity need to not only to address poor nutrition and physical
inactivity, but also increase the focus of these programs on obesity prevention, better integrate
activities, increase community understanding of the potential risks associated with overweight
and obesity at different stages of the life course and motivate and support a healthy lifestyle.
The national obesity action agendas for adults and children recommend that the prevention of
unhealthy weight gain should underpin population-based approaches to reduce obesity-related
harm. These should be supported by more targeted interventions for populations, groups and
individuals identified at high risk of obesity-related conditions.
There is limited evaluation of the effectiveness of population level interventions with

prevention of weight gain as the specific outcome (as distinct from changes in physical
activity or diet)[146]. Both national obesity action plans recommend approaches that build on
and integrate interventions targeting diet and physical activity. They emphasise the need for
a whole of community approach with a focus on health promoting environments to support
behaviour change.
37
Outcomes desired:
Slow, halt and eventually reverse the trend of increasing overweight and obesity.
Preventing weight gain of adults at the population level.
Optimising the healthy growth of children and adolescents.
Early reversal of unhealthy weight gain.

Whole of population at key intervention points across the life course:
infants and pre-school children
school age children and adolescents
young adults
pregnant women
parents of young children
adults aged 45 years and above.
Aboriginal people.
Other populations at increased risk of obesity-related ill health including people in rural
and remote areas and people with a disability.
People with other risk factors for chronic disease or with chronic diseases where better
weight management can delay progression and reduce complications.
1. Integrate nutrition and physical activity approaches.
2. Increase community awareness of healthy weight, the benefits of healthy weight, the
health risks associated with overweight and obesity and how to prevent weight gain.
3. Increase parents’ ability to establish healthy eating and physical activity behaviours
among children early in life.
4. Build community engagement, capacity and motivation for local action to address
environments and lifestyles that support overweight and obesity.
5. Increase risk assessment, early identification and brief intervention to prevent weight
gain among those identified at increased risk of chronic disease.
6. Early reversal of small unhealthy weight gains.
7. Work with sectors outside health to develop policy and programs addressing the
determinants of obesity.
38
1. Integrate nutrition and physical activity approaches

Opportunities exist to strengthen the impact of nutrition and physical activity interventions on
the prevention of weight gain. This can be achieved through the inclusion of stronger messages
about the need to balance energy intake and physical activity, use of consistent terminology
and recommendations, better linkages between programs and development of new programs
that incorporate both nutrition and physical activity components.
Actions
Implement effective interventions targeting physical activity and diet, as outlined in
earlier sections.
Include messages about the need to balance energy intake and physical activity in health
promotion programs that primarily target nutrition or physical activity.
Develop multi-risk factor healthy lifestyle programs that incorporate both nutrition and
physical activity components.
2. Increase community awareness of healthy weight, the benefits of healthy

weight, the health risks associated with overweight and obesity and how to
prevent weight gain
Theoretical models of behaviour change identify the need to ensure that people understand the
risks of unhealthy weight gain and how to avoid it, are motivated to change their behaviour in
relation to nutrition and physical activity, and are able to overcome barriers to change.
Actions
Implement population-based approaches to increase community awareness of healthy
weight, the benefits of healthy weight, healthy eating and an active lifestyle, the health
risks associated with overweight and obesity and how to prevent unhealthy weight gain
through appropriate dietary choices and physical activity (including clear, consistent
messages about these issues).
Develop targeted interventions for priority populations such as parents, Aboriginal people
and those living in lower socioeconomic circumstances.
3. Increase parents’ ability to establish healthy eating and physical activity

behaviours among children early in life
Parents play a key role in determining children’s attitudes, behaviours and access to food
and opportunities for physical activity[141]. Exclusive breastfeeding for at lest six months and
appropriate introduction of solid foods can promote healthier growth of infants and weight in
pre school years[23]. Food preferences and fundamental movement skills develop in pre school
years and provide the foundations for lifelong habits around eating and physical activity[147, 148].
Actions
Provide education programs and support to inform, skill and empower parents to
establish appropriate eating and physical activity patterns in children early in life.
39
4. Build community engagement, capacity and motivation for local action to

address environments and lifestyles that support overweight and obesity
The range of settings where people live, work and play, such as schools, workplaces and
communities offer opportunities to educate, motivate and support individuals to attain
and maintain a healthy weight. These settings-based approaches offer the opportunity for
integrated multi-risk factor interventions, such as combined nutrition and physical activity
programs to address overweight and obesity. Engagement of community members is important
to identify relevant issues and motivate implementation of identified solutions.
Actions
Support the implementation of childcare and school-based policy and programs to
promote both healthy nutrition and physical activity.
Develop comprehensive workplace programs and policies, incorporating both nutrition
and physical activity, with an emphasis on energy balance and the prevention of weight
gain.
Develop and/or implement evidence-based community interventions, healthy lifestyle
programs and self-help information resources that include both nutrition and physical
activity, particularly for individuals and populations at high risk of or with chronic
disease.
Engage communities and key stakeholders to develop and resource appropriate local
strategies and efforts to effectively tackle obesity.
5. Increase risk assessment, early identification and brief intervention to

prevent weight gain among those identified at increased risk of chronic
disease
The risk of developing a number of chronic diseases such as type 2 diabetes and cardiovascular
conditions is increased by overweight and obesity. The prevention of weight gain can not only
reduce the risk of some chronic diseases, but can also delay or reduce the development of
complications. While there is little information about the effectiveness of brief intervention
by health professionals to prevent excess weight gain, there is evidence that brief intervention
can change lifestyle related behaviours[149].
Actions
Increase the capacity of primary health care practitioners and other health professionals
to:
systematically assess weight, diet and physical activity as part of the early detection
of increased risk of chronic disease.
provide advice about links between weight and disease and undertake brief
intervention in relation to diet and physical activity for those at high risk of chronic
disease or with early chronic disease to reduce the risk of weight gain.
Develop information on links between weight, diet, physical activity and disease and
referral services for health and other professionals.
Increase access to affordable services including: specialist advice, self help information
and community-based advice, support and interventions for diet, physical activity and
weight management, particularly for individuals and populations at high risk of or with
chronic disease.
40
6. Early reversal of small unhealthy weight gains

Early reversal of small unhealthy weight gains increases the prospect of maintaining a healthy
weight[150, 151] and is particularly important for children to prevent persistence of weight
problems into adulthood[152, 153]. Both adults and children who experience excessive weight gain
may need support from health professionals to reverse this. Effective interventions need to
address both nutrition and physical activity and include behavioural therapy[139, 149, 154]. Family
involvement is particularly important in programs for children[143]. The National Health and
Medical Research Council has developed evidence-based clinical practice guidelines for the
management of overweight and obesity in adults, children and adolescents[141, 149].
Actions
Implement programs for adults and children to provide advice, support and appropriate
interventions for diet, physical activity and weight management, taking into account the
special needs of these individuals and factors contributing to the weight gain.
Integrate weight management programs for those at high risk of or with chronic diseases
exacerbated by excess weight gain into overall multidisciplinary care plans.
7. Work with sectors outside health to develop policy and programs

addressing the determinants of obesity
A sustained, multifaceted and integrated approach is needed to make a meaningful impact
on the many social, economic and physical factors that influence weight and unhealthy
lifestyle. This will require action from a broad range of government, non-government and
private agencies. The Premier’s Physical Activity Taskforce has a role in coordinating physical
activity policy and interventions across government. There is currently no formal structure or
mechanism to engage or coordinate agencies that can influence nutrition or obesity outcomes.
Actions
Lead the formation of partnerships with government and non-government sectors at
statewide and local level to support obesity prevention policy and program development
by sectors outside health.
Develop an obesity action plan in consultation with other key government and non-
government agencies, academic institutions and the community.
Engage communities and key stakeholders in the development of approaches to

effectively tackle the problem of obesity.
Enabling and implementation issues specific to promoting healthy weight

Sustained communication and advocacy to motivate community and individual action to
prevent and manage obesity.
Develop and implement appropriate diet, physical activity and obesity monitoring
systems for children and adults, with consideration of consistency with the monitoring
systems of other jurisdictions.
Increase the evidence base around the barriers and facilitators of weight-related
behaviours and effective population-based interventions.
41
Low risk alcohol use

Alcohol is consumed in moderation and enjoyed by many Western Australians. At the same
time, alcohol is a risk factor for both chronic disease and injury, as a result of its impact as a
drug and as a nutrient that contributes to overweight and obesity. Harmful alcohol consumption
is also a key factor in crime, social disruption, violence, lost productivity, property damage and
unsafe sexual practices.
Alcohol-related health problems are associated with three patterns of drinking[155].

Excessive alcohol intake on a particular occasion/drinking to intoxication can lead
to immediate or short-term effects such as alcohol-related injury and violence, road
trauma, other risk taking behaviours, stress, sleep problems, sexual dysfunction and
gastrointestinal problems.
Consistently high levels of intake can lead to longer-term health effects and chronic
disease, such as cirrhosis of the liver, some cancers, high blood pressure and stroke,
heart and blood disorders, gastrointestinal ulcers, pancreas damage, cognitive
impairment and loss of memory. High levels of alcohol consumption during pregnancy can
adversely affect the foetus, although there is debate about the risks associated with low
to moderate levels of consumption[156].
Alcohol dependence causes withdrawal symptoms, loss of control and social
disintegration.
The Australian Alcohol Guidelines define drinking patterns to avoid short-term or long-term
problems. The Dietary Guidelines for Australian Adults[87] set slightly lower recommended daily
levels based on alcohol’s contribution as a nutrient to weight problems. Even low levels of
alcohol consumption can increase the risk of some cancers, with the positively correlated with
the amount drunk[157].
While per capita alcohol consumption has declined in Western Australia and Australia over
the last two decades, more young people are drinking alcohol, drinking at an earlier age and
adopting high-risk drinking patterns[158].
Nearly two thirds of all alcohol consumed in Western Australia is drunk on occasions when total
consumption is at a level that can cause short-term harm, while almost half (44%) is drunk by
people who exceed the guidelines for avoiding chronic harm[159].
Alcohol use
In 2004 in Western Australia 11% of those aged 14 and over drank at levels that put their
health at risk in the long term. Two in five (39%) drank at levels that put their health at
risk in the short-term (at least once in the last year)[24].
The majority of alcohol-related problems are caused by those who occasionally drink
excessive amounts of alcohol[160]. There are far more people who get drunk occasionally
than there are people who regularly drink heavily[24].
Western Australia ranks second only to the Northern Territory in terms of per capita
alcohol consumption[159].
42
Alcohol use (cont.)

Some Western Australian populations have higher levels of harmful drinking:
males (for harm in the short term)
[24]
young adults aged 20-29

[24]
adolescents (one in four 12-17 year old school students drink at levels that place them
at risk of immediate harm)[25] and almost 80% of the alcohol they consume is drunk in
circumstances that put their health at risk of acute harm[161].
Fewer Aboriginal people drink but those who do are likely to drink in a harmful way or
experience harm[162].
Rates of alcohol-related harm are higher in rural areas, particularly the Kimberley .
[163]
Each year, harmful alcohol use is responsible for more than 300 deaths and nearly 10,000
hospitalisations in Western Australia, costing the state around $32 million[164].
In 1998/99 the social cost of alcohol problems in Western Australia was conservatively
estimated at $750 million[165].
The Western Australian Alcohol Plan 2006-2009 recommends that the health impacts of alcohol
should be addressed within a whole of population approach. This should focus on reducing
the social acceptability of drunken behaviour and creating environments that minimise the
potential problems from excess alcohol use. This approach provides benefits for the entire
population, as well as high-risk groups such as young people, people from rural and remote
communities, Aboriginal people, those with coexisting mental health and drug and alcohol
problems and culturally and linguistically diverse populations.
Reducing alcohol-related harm needs to take into account not just total consumption but
patterns of drinking, settings, characteristics of drinkers and beverages being consumed[155].
Current evidence supports a multi-strategic approach involving the regulation of alcohol sales
and marketing, social marketing campaigns, drink driving initiatives, reorientation of health
services, community interventions and targeted investment in early childhood development.
Outcomes desired:
Reduce the prevalence of harmful alcohol consumption.
Reduce alcohol-related harm.
Decreasing community acceptance of drunkenness and associated problems.
Motivating and supporting low-risk drinking.
Creating drinking environments that minimise harmful alcohol consumption.
43

Whole population to address cultural aspects of alcohol consumption.
Young people who drink at potentially harmful levels.
Aboriginal people who drink at potentially harmful levels.
People at high risk of chronic disease or with chronic disease.
Women of child-bearing age.
1. Appropriately regulate the physical availability of alcohol.
2. Reduce community acceptance of drunkenness and associated behaviour.
3. Increase the responsible service, marketing and promotion of alcohol.
4. Increase risk assessment, early identification and brief intervention for those consuming
alcohol at potentially harmful levels.
5. Advocate for alcohol pricing that limits harmful alcohol consumption.
More specific directions are outlined in the Western Australian Alcohol Plan 2006-2009 and the
Strong Spirit Strong Mind: Western Australian Aboriginal Alcohol and Other Drugs Plan
2005–2009.
1. Appropriately regulate the physical availability of alcohol

The links between the availability of alcohol and both consumption levels and alcohol related
harm are well documented. Key factors that can impact on alcohol consumption and alcohol
related harm include the extent of liquor licenses, outlet density and trading hours[166].
Actions
Regulate the physical availability of alcohol through statewide and local support for
appropriate liquor licenses, outlet density and trading hours through interventions under
the Western Australian Liquor Licensing Act 2007.
Implement initiatives to support safer drinking environments through education about

responsible supply of alcohol and event organisers’ responsibilities in unlicensed settings
and at public events.
Work with agencies, groups and communities (including Aboriginal communities) to

develop and implement appropriate alcohol management policies.
2. Reduce community acceptance of drunkenness and associated behaviour

Previous mass media campaigns to reduce harmful drinking among young people have not been
successful in changing drinking behaviour and associated short-term harm. They have been
successful in increasing awareness and knowledge of the negative consequences of high risk
drinking[167].
44
Getting drunk is considered normal by many Australians. The high level of community
acceptance of the negative behaviours associated with drunkenness is a key factor in the
high number of alcohol-related problems experienced by the community. There is a need
to increase community understanding about how these cultural norms are contributing to
risky consumption and alcohol-related harm, and to reduce the acceptability of drunkenness
and associated behaviour. Mass media campaigns have been effective in raising awareness,
reinforcing environmental controls and changing social norms about the acceptability of issues
such as drink driving[167].
There are low levels of public awareness about the potential impact of alcohol on the risk of
chronic disease and on its impact on the developing foetus[155].
Actions
Implement sustained public education programs, including mass media campaigns, to
reduce community acceptance of drunkenness and associated problematic behaviours and
to increase support for policy initiatives that reduce alcohol-related harm.
Develop and implement culturally appropriate local programs, resources and publications
for Aboriginal people and other high-risk groups.
Continue public education about the potential harmful effects of alcohol, targeting
people at high risk of or with chronic disease and women of childbearing age.
3. I ncrease the responsible service, marketing and promotion of alcohol

Safer drinking environments can be created through the responsible service of alcohol in
both licensed and unlicensed settings and by limiting promotions that encourage the rapid
consumption of alcohol. This approach can result in sustainable reductions in the problems
related to risky or high-risk alcohol consumption, particularly injuries and immediate harm[167].
Actions
Promote and support responsible service, marketing and promotion of alcohol that will
limit the potential for alcohol-related harm by:
Ensuring compliance with alcohol-related regulations and responsible service training
requirements.
Advocating for reform of alcohol advertising and other promotional regulatory
regimes, including eliminating exposure of children to alcohol advertising.
Supporting agencies, groups and communities, particularly Aboriginal communities, to
develop and implement appropriate local interventions targeting responsible service,
marketing and promotion of alcohol.
4. Increase risk assessment, early identification and brief intervention for

those consuming alcohol at potentially harmful levels
Alcohol consumption can increase the risk of developing some chronic diseases and associated
complications[155]. Opportunistic brief interventions can be used to screen, detect and intervene
among those drinking at harmful levels before injury occurs, or before health problems or
dependence develop[164]. Brief intervention has been shown to be cost effective if widely
implemented. It can be delivered by a range of trained health professionals in a number of
settings, particularly in primary care and general hospital settings.
45
Brief interventions can complement existing effective treatment services for those seeking help
for an alcohol problem. There are a number of effective treatments for individuals identified as
drinking at potentially harmful levels or with alcohol dependence[167-169].
Actions
Support early identification and brief intervention for those drinking at levels that place
them at risk of injury or chronic disease or that that could harm a developing foetus.
This should be part of the core business of all health services (including hospitals,
primary health care and Aboriginal services) with referral to specialist services where
appropriate.
Build workforce capacity to provide brief intervention for low-risk alcohol consumption
(which in some cases may mean abstinence), including provision of information about the
links between alcohol and chronic disease and injury.
Incorporate alcohol advice into chronic disease and self-management programs.
5. Advocate for alcohol pricing that limits harmful alcohol consumption

There is evidence that increases in the price of alcohol usually lead to an overall reduction in
consumption and that decreases in price lead to an increase in consumption and alcohol related
harm. Cheap cask and fortified wines, taxed by wholesale value rather than alcohol content,
are strongly associated with alcohol-related violence and hospitalisations[167, 168, 170].
Actions
Encourage the Commonwealth Government (responsible for taxation of alcohol) to
investigate the feasibility of introducing a uniform volumetric tax on all alcohol products.
Advocate for state-based opportunities for alcohol pricing that reduces alcohol-related
harm.
Enabling and implementation issues specific to promote low-risk alcohol use

Advocate for alcohol control policy and compliance initiatives nationally and within
Western Australia’s jurisdictional control, in the areas of pricing, advertising and
promotion, and access and availability of safer drinking settings.
Increase linkages between alcohol education and other disease or lifestyle related
programs and strengthen alcohol messages in other chronic disease prevention and self-
management initiatives.
Improve the availability of information for policy and program development, specifically:
Improve the collection of alcohol-related harm data in emergency departments in non-
metropolitan areas.
Support the ongoing collection and reporting of wholesale alcohol sales data as a key
indicator of consumption.
46
Preventing injury
The National Injury Prevention and Safety Promotion Plan[171] defines injury as ‘physical harm
to a person’s body’, which can be unintentional injury, self harm or harm to others. Safety is
defined as “being at little or no risk of injury”, and can include perceptions of risk.
The risk of injury is influenced by the physical environments in which people live (such as
buildings, road and vehicle design), lifestyle and behaviour (such as excess speed, drink driving
and poor supervision) and physiological (such as fatigue, poor eyesight and pre-existing medical
conditions) and other factors (such as lack of training and exposure to stressful events).
There is a strong relationship between low socioeconomic environments and increased risk of
injury[43]. In addition the risk of injury is influenced by gender and life stage, which determine
activities and choices that affect safety[171].
Changing environmental conditions can reduce the risk of injury. The likelihood and severity
of injury can also be reduced by the use of protective equipment and products. The level of
access to acute care and rehabilitation services will influence the level of harm from injuries
and longer-term consequences. To improve safety, prevent injury and reduce harm on both a
population and individual level, there needs to be:
a positive safety culture: with high awareness of injuries and how to prevent them, the
importance of action and willingness to take that action.
safer environments and products: the social and physical surroundings or conditions
that support the prevention of injury, including socio-cultural circumstances, safer
products, workplaces, roads, homes, public spaces and recreational facilities.
Injury
In 2005, approximately one in five Western Australians (of all ages) and 16% of Western
Australian children aged 0 to 15 years reported having had an injury in the last year that
required treatment by a health professional [172].
The leading causes of injury related harm and health care cost in Western Australia are
falls, road trauma, self-harm and suicide, interpersonal violence, accidental poisoning and
other unintentional injuries[15].
Falls are the single most expensive cause of non-fatal injury in Western Australia (31% of
the total cost of injury and 25% of injury-related health system costs in 2003). If current
trends continue, costs from falls among older people will double by 2021[16].
Drowning is the leading cause of preventable death in infants and children up to four years
of age in Western Australia[173].
Groups with significantly increased rates of injuries and/or related harm in Western
Australia are:
Aboriginal people .
[171, 174]
People living in rural and remote areas .

[171]
Males, particularly 16-44 year olds . Males account for 70% of the total cost of injury
[172]
including health system, quality of life and indirect costs[16].
47
Injury (cont.)
Alcohol is a key factor in injury: 33% of injuries overall, 37% of fire injuries and 45% of
assault presentations at Western Australian Emergency Departments were related to
alcohol in 2005/06[164].
Each year injury and poisoning is responsible for approximately 40,000 hospital admissions,
800 deaths and 80,000 emergency department presentations in Western Australia[172].
Injury costs the Western Australian health system $434 million for treatment and other
health care resources[16].
The National Injury Prevention and Safety Promotion Plan promotes the use of a population
approach to injury prevention, targeting different life stages and population groups. It
recognises the changing injury risks and opportunities for prevention across the life course as a
result of changes in capabilities, activities, circumstances and knowledge.
Best practice guidelines recommend that to be effective, injury control interventions must
take a comprehensive approach that addresses at least one or more of the following: creating
a low risk population; increasing awareness and identification of risk; reducing risk factors for
injury; creating safer environments, settings and products; and improving the links between
the prevention and management of injuries.
Alcohol use is a risk factor for many types of injury. Decreasing harmful drinking can result in
a reduced incidence of injury in the community, particularly in relation to road trauma, self-
harm, suicide and drowning.
The strategic directions within this section have been based on current levels of harm and
cost to the community and health systems. There will continue to be emerging issues due to
changes in lifestyle and as better information about injury rates becomes available.
While suicide and self-harm are responsible for a significant proportion of injury related harm,
strategies for addressing these are not included in the WA HPSF. In Western Australia, the
Ministerial Council for Suicide Prevention is responsible for coordinating suicide prevention
initiatives and developing strategies to reduce suicide amongst populations who are at high risk
of suicide.
The Western Australian Mental Health Safety Advisory Group, established to assist with the
implementation of major reforms to mental health services in Western Australia, is currently
developing a work plan in response to the National Safety Priorities in Mental Health Plan.
Reducing suicide and deliberate self-harm in mental health and related health care settings is a
key priority within this work.
48
Outcomes desired:
Reduce the incidence of injury.
Reduce the harm associated with injuries.

Whole of population at key life stages (particularly children, young people and older
adults).
Males at all ages, particularly 16-44 year olds.

Aboriginal people.
Those living in rural and remote areas.
Strategic Directions
1. Reduce falls and related harm in older people.
2. Reduce falls, accidental poisoning and burns and scalds in children.
3. Reduce road trauma, particularly among young males.
4. Reduce drowning and near drowning in children and adults.
5. Contribute to reducing the harm from violence and assault.
6. Reduce injuries in males from falls and ‘do it yourself’ (DIY) injuries.
1. Reduce falls and related harm in older people

While falls occur across the whole lifespan, priority will be given to the prevention of falls
and falls-related injuries in older people aged 65 and above. Two fifths of falls related
hospitalisations and four fifths of falls-related deaths occur in this age group[15]. One in ten
(10%) Western Australian women and six per cent of men aged 65 and older report at least one
fall related injury that requires treatment a year[175]. One in four people aged 60 and above fall
at least once a year[176].
There is a growing body of evidence that falls and fall-related injury among older people
can be prevented at an individual and population level, with the highest rates of return from
approaches that combine a range of interventions addressing the major risk factors for falls[177].
Given the high rate of falls in residential aged care and acute care settings[178, 179], falls will be
targeted in both of these settings as well as in home and community settings.
Key target groups will be the overall population, Aboriginal people and those living in rural and
remote areas, including:
The well population: to create a low risk population of older people.

Older people at increased risk of falls: to reduce the risk of falls.
People experiencing falls: to reduce the harm associated with falls.
49
Actions
Create a low risk population of older people and promote independence:
Promote lifelong healthy diet and physical activity to reduce the risk of osteoporosis,
maintain health and fitness and prevent chronic conditions.
Educate older people and carers/family about the preventative nature of falls and key
risk factors for falls.
Promote and support development of lifestyle and exercise programs for older people
to improve balance and strength.
Increase awareness and identification of risk:

Support and build the willingness and capacity of the health workforce (including
Aged Care Assessment Teams, general practitioners, hospital staff, community
health workers, staff in residential aged care facilities and staff in non-government
organisations and community agencies) to regularly assess and review the risk of falls
and advise on or implement strategies to prevent falls and related injury.
Reduce risk factors for falls and fall related injury:

Support the development of policies to prevent falls and related injuries in acute care
facilities, residential aged care facilities and the community.
Implement multi-factorial evidence based programs that address falls risk factors,
such as physical activity with a focus on balance and strength, home safety audits
and changes to the environment, review of medications, spectacles and footwear,
continence management, expedited cataract surgery, cardiovascular assessment, and
osteoporosis and dietary assessment.
Implement interventions for high-risk individuals that include the use of hip protectors
and occupational therapy.
Facilitate appropriate referral and access to other services and prevention services.
Develop local partnerships to facilitate implementation of community based falls
programs.
Create safer environments, settings and products:

Educate older people and carers/families about environmental risk factors
(inadequate footwear or visual aids, inappropriate walking aids, uneven floor or
walking surfaces, poor lighting, inappropriate height of chairs and beds, poor housing
design).
Develop policies to prevent falls in acute and residential aged care facilities.
Advocate for and support the development of safer products and environments in
residences, public spaces and facilities.
Advocate for falls prevention to be a priority for all community groups and agencies
that provide products, services and information to older people.
Improve links between the prevention and management of injury:

Improve the interface between older people’s place of residence and primary care,
hospital emergency departments and outpatient clinics where people attend for care
following a fall or other conditions that might increase the risk of falls.
Develop a culture of falls prevention to ensure appropriate risk assessment, referral to
clinical or intervention services and discharge procedures.
50
2. Reduce falls, accidental poisoning and burns and scalds in children

The key causes of injury-related deaths in children are drowning, road trauma (particularly
pedestrian injuries) and interpersonal violence. Injury-related hospitalisations are mainly from
falls, cycling, road trauma, poisoning and burns[171]. A quarter of falls related hospitalisations
occur in children under 15 and two fifths of accidental poisoning and just under a third of burns
and scalds related hospitalisations occur in children up to four years of age. Aboriginal children
are particularly vulnerable to these injuries[15].
Preventing these childhood injuries requires parent education (such as awareness of injury
risks and interventions in the home), environmental interventions (such as safe furniture,
smoke alarms and safe medicine storage) and appropriate regulations, legislation (such as bike
helmets, pool fencing and seat belts) and national design standards.
Injury prevention initiatives targeting infants and young children should form part of a
holistic approach to health, safety, education and welfare that addresses the risk factors for
other problems in childhood, such as living in a family or community affected by alcohol.
Among older children approaches should focus on preventing serious injury and assisting the
development of risk management strategies.
Key target groups will be children up to 14 years of age, particularly boys; parents of children
this age, Aboriginal people; and people living in rural and remote areas.
Actions
Educate parents, particularly in relation to the need for child supervision, safe home
environments, safety training and appropriate equipment in home and outside, falls
prevention, accidental poisoning risks, safe storage of medicines and appropriate
treatment of minor burns and scalds in the home.
Educate carers, school and recreational professionals about the risks and prevention of
falls in children.
Advocate for and support:

Improved safety of home and playground products and for compliance with relevant
Australian Standards for surfacing and equipment.
Improved regulation of packaging of common medicinal and non-medicinal poisoning
agents consistent with international standards.
Expansion of national smoke alarm legislation to existing housing (both rental and
public).
Legislation to regulate hot water temperatures in all homes, with education and
policies for public housing.
3. Reduce road trauma, particularly among young males

Transport-related, particularly road crashes, are responsible for a considerable burden of
disease and cost to the health system, and one quarter of the total cost of injury to the
community[16].
The Office of Road Safety leads the development and implementation of road safety policy in
Western Australia. WA Health is a member of the Road Safety Council of Western Australia,
participating in strategic planning and road safety partnership initiatives.
51
The Arriving Safely: Road Safety Strategy for Western Australia 2003-2007 focuses on a ‘safer
systems’ approach to road safety. The aim is to develop an effective system-based approach to
road safety that includes initiatives to improve the safety of vehicles and roads, develop safer
drivers (through driver education and enforcement of compliance with regulations) travelling at
safer speeds, and to share responsibility for road safety across the community, government and
vehicle industry.
Key target groups for the prevention of road trauma will be males 16 to 44 years of age; people
living in rural and remote areas; Aboriginal people; and impaired driversh.
Actions
Through the Road Safety Council of WA, actively contribute to the review and
management of policy, legislation and regulations that impact on road safety and support
the implementation of Western Australian road safety strategies and plans.
Support the development and implementation of initiatives related to the prevention of

drink and drug driving.
Support the implementation of the School Drug Education and Road Aware Program in
Western Australian schools.
Participate in local and regional road safety coordinating groups and local road safety
initiatives, including supporting fitting and checking child car restraints and the safety of
children around cars.
Develop Aboriginal initiatives in alcohol and road safety.

Improve communications and partnerships between health professionals, licensing
authorities and police to address issues around impaired drivers.
Implement a WA Health vehicle safety policy that addresses the selection of safer
vehicles and fittings that promote occupant safety, and includes safer user procedures
and policies.
4. Reduce drowning and near drowning in children and young adults

Those at highest risk of drowning include young children up to and including four years of age,
young people (particularly males) and people living in rural and remote areas. Half of all deaths
occur while boating and fishing. While deaths are relatively small, for every death there are
another six hospitalisations for near drowning[173].
For children, the key contributing factors are inadequate swimming pool fencing, safety
barriers, and adult supervision around pools, baths, fish/garden ponds and wading pools. For
adults, key factors include alcohol and other drug use (involved in one in four drowning deaths
in those aged 15 and above and almost half of those in 15 to 29-year-olds), swimming in risky
settings and inability to swim.
Key target groups will be parents of children up to four years of age; males aged 16 to 35
years; and people living in rural and remote areas.
Impaired drivers includes drivers of any age with an impairment such as visual problems, recent head injury
h
and epilepsy.
52
Actions
Improve parents’ knowledge of the risks of toddler drowning and compliance with pool
and spa fencing regulations.
Improve awareness by young males and people in rural and remote areas of the risks
associated with aquatic activities, particularly when drinking alcohol.
Work with other agencies, including Commonwealth, State and local government, to
contribute to the review and management of policy, legislation and regulations that
impact on aquatic safety through creating safer environments.
5. Contribute to reducing the harm from violence and assault

Interpersonal violence includes homicide and assault and both family and community violence.
In 2003, over 4,500 people were seriously assaulted in Western Australia[180]. Key groups
experiencing violence and assault are young men, women and children. Rates of harm are
particularly high among Aboriginal people[15].
Approaches to reducing violence and assault need to focus on the underlying factors that
contribute to interpersonal violence by working with families and communities to foster
positive child development pathways, strengthen protective factors and reduce risk factors
at transition points in the lifecycle. Other key approaches include alcohol control measures,
programs targeting domestic violence and increasing the security of public spaces.
Responsibility for preventing interpersonal violence is shared across a number of government

agencies. A number of Western Australian strategies and plans address domestic violence, drug
and alcohol use, crime prevention, mental health and building resilience through interventions
in early years.
The health sector is well positioned to have an impact on violence and assault. Key target
groups for health promotion approaches are children (at key life phases and transition points);
males 15 to 44 years of age; Aboriginal people; and people in rural and remote areas.
Actions
Collaborate with other agencies and communities at statewide and local level to address
the complex social problems such as drug and alcohol related harm, crime prevention,
child abuse, domestic violence and youth suicide.
Implement comprehensive health promotion approaches that limit excessive alcohol
consumption by those involved in violence and assault.
Support schools to adopt comprehensive school-based interventions focusing on reducing
violence and bullying in the school setting.
Create local coalitions of business, government, community and leaders to work together
and coordinate activities to address safety within local communities and prevent and
minimise injuries, including violence and assault (Safe Communities).
53
6. Reduce injuries in males from falls and DIY injuries

Falls in adult males are related to ‘do it yourself’ (DIY) activities, sport and occupational
activities. National and international data suggest that DIY injuries are becoming increasingly
problematic, particularly among males aged 25 to 44 years and those aged 60 and over[181].
Currently, Western Australia does not have a surveillance system to ascertain the size of the
problem and potential methods of prevention. Key risk factors are the non-use of protective
equipment, inappropriate tools and insufficient safety precautions.
The key target group will be males.
Actions
Education and awareness raising about the risks DIY activities.
Work with other government agencies and industry to ensure falls prevention is
highlighted for occupational health and safety, DIY activities and sport.
Enabling and implementation issues specific to preventing injury

Influence state and national policy, regulations and legislation around safer products,
environments and safety related behaviour to prevent injury, including access to alcohol
and use around injury risk settings, improved safety of home and playground products
and compliance with relevant Australian Standards for surfacing and equipment.
Increase linkages between the prevention and management of injuries.

Work with Aboriginal community leaders to increase the priority on injury prevention and
safety.
Build health workforce capacity to assess injury risks and advise or refer to appropriate
services.
Collaborate across government to improve the availability of information for policy and
program development, specifically:
Better information on rates and causes of certain injuries, including: transport related
injuries, ‘do it yourself’ injuries, injuries in Aboriginal people, involvement of alcohol,
interpersonal violence, drowning, ‘other’ unintentional injuries, location of injury and
emerging issues.
Collect information among high risk groups.
More timely and regular reporting of injury related hospital and mortality data.
Improve the evidence base for effective interventions in injury prevention.
54
Organisational enabling and implementation actions

The Western Australian Health Promotion Strategic Framework 2006-2011 (WA HPSF) outlines
the strategic directions for the Western Australian health system for the next five years. The
WA HPSF is not an action plan. It does not attempt to prescribe specific actions for health
services but rather to identify priority areas for action by the Western Australian health system
at statewide and community level.
The strategic directions outlined in this document build on the considerable past and existing
work in this area. Implementing this agenda will require long-term commitment and the
involvement of all parts of the health sector. It is not expected that all the actions outlined
here will be achieved in five years, but rather that progress will made towards all of these
during this time.
For this reason the WA HPSF does not include an evaluation plan. Instead, a key
implementation action will be the development of suitable information and reporting
mechanisms to monitor the outcomes outlined in the framework.
A number of organisational and system-level changes and actions are needed to underpin
the implementation of the strategic directions: leadership, policy and strategic planning,
partnerships, coordination, integration, workforce capacity building, surveillance and research
and appropriate resource allocation.
The Health Networks will play an important role in leading the reorientation of the health
system towards prevention of injury and chronic disease through collaborative policy
development, priority setting and planning. The WA HSPF will be implemented through the
actions of a range of health services at both statewide and regional level, building on the work
of key programs such as the Chronic Disease Management Teams and the Australian Better
Health Initiative. Some campaigns and programs will be provided under contract by non-
government agencies as part of the Government’s commitment to devolve responsibility and
funding for major health promotion campaigns and programs to this sector.
Leadership, policy and strategic planning

The health system has a vital leadership role in the development and evaluation of appropriate
consistent statewide policy in the areas of tobacco control, nutrition, physical activity,
overweight and obesity, alcohol control and injury prevention.
Key actions include:

Actively engage with a broad range of government, non-government and other agencies
to influence the development of public policy, legislation, environments and community
infrastructure to support healthy lifestyles and prevent injury.
Continue to influence national policy on issues such as tobacco and alcohol taxation,
advertising of food and alcohol, access to pharmacotherapies and product safety.
Lead broader workplace reform through the implementation of healthy lifestyle policy
within WA Health, particularly for healthy food supply, tobacco and alcohol control,
responsible alcohol service, physical activity, safe fleet policies and falls prevention.
55
Partnerships, coordination and integration

The prevention of chronic disease and injury requires whole of government and whole
of community approaches. Effective health promotion approaches require partnerships
at national, statewide and local levels to develop appropriate public policy, strengthen
community action, reorientate health services and create supportive environments.

Actively collaborate with sectors outside health, at statewide and regional level, to
address factors that impact on social disadvantage and the social and other determinants
of disease and injury.
Through Health Networks and related coordinating groups, better link policy and program
development across health services, local government, non-government agencies and
primary care services, and between prevention and management activities.
Develop local partnerships to facilitate community based program implementation.

Work with local communities to foster leadership to empower communities to act.
Develop greater linkages, consistency and synergy between statewide media campaigns
and programs and community or service level activities.
Better link initiatives and services targeting different behavioural risk factors.
Include community representatives in decision-making processes.
Strategic partnerships are required with a broad range of stakeholders:
Commonwealth, State and Territory governments
other relevant State and local government agencies
sectors within the health system, including public health, acute care, Aboriginal health,
primary care, aged care, mental health and drug and alcohol services
general practitioners and private health care facilities

non-government agencies
Aboriginal health and medical services and non-government agencies
Aboriginal and non-Aboriginal communities
community services and aged care facilities
industry
educational and academic institutions.
Workforce capacity building

Increasing the focus of the health system on promoting and supporting a healthier and safer
lifestyle will require workforce development, not only for public health professionals, but also
for a broad range of professionals working in primary care, community health, allied health,
hospitals, residential care and other settings.
56

Strengthen and sustain health service support for health promotion activities.
Build health professionals’ knowledge of health promotion practices around injury
prevention and smoking cessation, physical activity, healthy eating, healthy weight and
low risk alcohol use.
Review and adapt screening tools, educational support, referral materials and
information about locally available lifestyle services for use by health professionals.
Build capacity of health professionals to undertake as part of core business:

more systematic lifestyle risk assessment and brief intervention.
injury risk assessments and interventions, including referrals, particularly around falls.
Build Aboriginal Health Workers’ capacity to undertake health promotion activities.
Improve skills in working with Aboriginal people in the non-Aboriginal health workforce.
Build capacity to develop programs for people from culturally diverse backgrounds.
Negotiate for the inclusion of healthy lifestyle risk reduction and brief intervention
training in relevant undergraduate courses and other training.
Monitoring, surveillance and research

Timely reliable data on population trends around the incidence of injury and the prevalence
of chronic disease and risk factors are needed for effective policy, planning, program
development, advocacy and evaluation. Information needs to be available at both state and
regional level to support local level planning and monitoring of integrated strategies. The
evidence base for prevention interventions also needs strengthening in some key areas.

Maintain existing statewide risk factor monitoring systems and improve monitoring of
nutrition, physical activity, obesity and the biomedical risk factors.
Improve monitoring and reporting in priority populations.

Improve the surveillance and reporting of injury and related harm.
Invest in developing a better evidence base about effective interventions to prevent
lifestyle related conditions and injury, particularly for Aboriginal people.
Identify ways in which health promotion programs can better address social determinants
that impact on potential program effectiveness.
57
Appendices
APPENDIX 1: Background to the development of the Western

Australian Health Promotion Strategic Framework 2007-2011
The Population Health Policy Branch, Department of Health (DOH), co-ordinated development
of the WA HPSF, with guidance from an Advisory Group and input from Expert Working Groups.
The Expert Working Groups were supported by Susan Leivers, Margaret Miller, Gemma Campbell
and Alison Burge (Population Health Policy Branch).
Members of the Advisory Group and Expert Working Groups are listed below.
Advisory Group
Dr Gervase Chaney Princess Margaret Hospital
Neil Fong Health Policy and Clinical Reform, DOH
Neil Guard Healthway
Dr Bret Hart North Metropolitan Area Health Service
Dr David Hurley Clinical Lead Endocrine Health Network, Royal Perth Hospital
Prof. Moyaz Jiwa WA Centre for Cancer and Palliative Care
Mark Morrissey Child and Adolescent Health Service
Terry Murphy Drug and Alcohol Office (Chair)
Susan Leivers Health Policy and Clinical Reform, DOH
Mike Pervan Health Reform Implementation Taskforce
Dr Sudhakar Rao Royal Perth Hospital
Dr Mandy Seel South Metropolitan Population Health Unit
Denise Sullivan The Cancer Council WA
Maurice Swanson National Heart Foundation WA
Dr Simon Towler Health Policy and Clinical Reform, DOH
Melissa Vernon WA Country Health Services
Tobacco Expert Working Group

Dr Owen Carter Curtin University of Technology
Dr Jo Clarkson Healthway
Prof. Mike Daube Curtin University of Technology
Julia Dick WA Country Health Service
Dr Jon Emery School of Primary, Aboriginal and Rural Health Care,
University of WA
Jackie Fay WA GP Network
Roslyn Frances Health System Support, DOH
Steven Hall Australian Council for Smoking and Health
Terry Murphy Drug and Alcohol Office (Chair)
Paul Reilly Fremantle Hospital
Dr Stephen Stick Women’s Health Service
Denise Sullivan The Cancer Council WA
Maurice Swanson National Heart Foundation (WA)
Clive Walley Curtin University of Technology
Dishan Weerasooriya Health System Support, DOH
58
Nutrition Expert Working Group

Andrea Begley Curtin University
Ana Gowrea Child and Adolescent Health Service
Di Ledger Diabetes Australia WA
Kathy MacKay South Metro Population Health Unit
Margaret Miller Health Policy and Clinical Reform, DOH (Chair)
Nadine Paull Wheatbelt Population Health Unit
Jane Pearce North Metropolitan Area Health Service
Christina Pollard Health System Support, DOH
Sandra Radich Child and Adolescent Health Service
Terry Slevin The Cancer Council WA
Noni Walker Walker Shandley Consultancy
Sonia White National Heart Foundation (WA)
Early Years Expert Working Group

Dr Gervase Chaney Co-lead Child and Youth Network, Princess Margaret Hospital
Dr David Forbes Co-lead Child and Youth Network, Princess Margaret Hospital
Dr Bret Hart North Metropolitan Area Health Service (Chair)
Tanyana Jackiewicz Telethon Institute for Child Health Research
Wynne James Office of Mental Health, DOH
Mark Morrissey Child and Adolescent Health Service
Colleen O’Leary Princess Margaret Hospital
Nicky Scrivener Health Policy and Clinical Reform, DOH
Prof. Fiona Stanley Telethon Institute for Child Health Research
Judy Straton Child and Adolescent Health Service
Dr Katie Thomas Curtin University of Technology
Judy Walsh State Child Development Centre, DOH
Alcohol Expert Working Group

Dr Tanya Chikritzhs Curtin University of Technology
Cliff Collard Drug and Alcohol Office
Chris Costa Injury Control Council WA
Susan Gatti Goldfields Population Health Unit
Naomi Henrickson Drug and Alcohol Office
Gary Kirby Drug and Alcohol Office (Chair)
Megan Milligan Armadale Community Health Service
A/Prof. Moira Sim Edith Cowan University
A/Prof. Ilse O’Ferrall University of Notre Dame
59
Physical Activity Expert Working Group

Lisa Bayly Department of Education and Training
Tom Briffa National Heart Foundation (WA)
Richard Crane South Metropolitan Population Health Unit
A/Prof. Billie Giles-Corti University of WA
Jane Hannaford Premier’s Physical Activity Taskforce
Jo Hart Diabetes Australia WA
Anna McDonald WA Country Health Service
Rex Milligan Health System Support, DOH
Steve Pratt The Cancer Council WA
Terri Quinlan WA Country Health Service
Jennifer Riatti Premier’s Physical Activity Taskforce
Trevor Shilton National Heart Foundation (WA)
Charlotte Steed Osborne Park Health Service
Dr Melissa Stoneham Stoneham and Associates
Injury Expert Working Group

Dr Rina Cercerelli Edith Cowan University
Chris Costa Injury Control Council WA
Colleen Fisher Edith Cowan University
Marea Gent Health Policy and Clinical Reform, DOH
Jon Gibson Office of Road Safety
Dr Andrew Guilfoyle Edith Cowan University
Jill Jarvis WA Country Health Service
Andrea Lomman Health Policy and Clinical Reform, DoH
Ken Marston Council of the Ageing
Dr Sudhakar Rao Royal Perth Hospital (Chair)
Dr Hannah Seymour Health Policy and Clinical Reform, DoH
Greg Tate Royal Life Saving Society
Sue Wicks Kidsafe WA
Social Determinants Expert Working Group

Ann Barblett South Metropolitan Population Health Unit
Denise Ferrier Child and Adolescent Health Service
Dr Bret Hart North Metropolitan Area Health Service
Dr Ray James Curtin University of Technology
Wynne James Office of Mental Health, DOH
A/Prof. Ilse O’Ferrall Notre Dame University
A/Prof. Sandra Thompson Centre for International Health, Curtin University of Technology
Melissa Vernon WA Country Health Services
Dr Lisa Wood School of Population Health, UWA
60
APPENDIX 2: Relevant endorsed National and State strategies/

action plans
WA policies and plans

A Healthy Future for Western Australians. Final report of the Health Reform Committee
Arriving Safely: Road Safety Strategy for Western Australia, 2003-2007
Crime Prevention. State Community Safety and Crime Prevention Strategy (2004)
Department of Health Strategic Intent 2005-2010
Early Years Strategic Framework 2003-2006
Eat Well Be Active: A Strategic Framework for Public Health Nutrition and Physical Activity,
2004-2010
The Falls Policy for Older Western Australians (2003)

Healthway Strategic Plan 2004-2007
Healthy Lifestyles: A Strategic Framework for the Primary Prevention of Diabetes and
Cardiovascular Disease in Western Australia 2002-2007
State Aged Care Plan for Western Australia 2003-2008

Strategic Intent 2005-2010 (Department of Health)
Strong Spirit Strong Mind: Western Australian Aboriginal Alcohol and Other Drugs Plan 2005–
2009
West Australian Aboriginal and Torres Strait Islander Health Promotion Plan 2005-2008
Western Australia Aboriginal Sexual Health Strategy 2005-2008
Western Australian Chronic Respiratory Disease: Clinical Service Improvement Framework
Western Australian Diabetes Strategy (1999)
Western Australian Drug and Alcohol Strategy 2005-2009
Western Australian Family and Domestic Violence State Strategic Plan: 2004-2008
Western Australian Hepatitis C Action Plan 2006-2008
Western Australian HIV/AIDS Action Plan 2006-2008
Western Australian Sexually Transmitted Infections Action Plan 2006-2008
Western Australian Water Safety Framework 2004-2007
Western Australia’s Mental Health Strategy 2004-2007
61
National chronic disease strategies

National Chronic Disease Strategy (2005)
National Service Improvement Framework for Asthma (2005)
National Service Improvement Framework for Cancer (2005)
National Service Improvement Framework for Diabetes (2005)
National Service Improvement Framework for Heart, Stroke and Vascular Disease (2005)
National Service Improvement Framework for Osteoarthritis, Rheumatoid Arthritis and
Osteoporosis (2005)
National risk factor strategies

Be Active Australia: 2005-2010
Eat Well Australia: 2000-2010
National Aboriginal and Torres Strait Islander Nutrition Strategy and Action Plan 2000-2010
National Alcohol Strategy 2006-2009. Towards Safer Drinking Cultures
National Drug Strategy-Aboriginal and Torres Strait Islander Peoples 2003-2009
National Tobacco Strategy 2004-2009
National injury strategies

National Aboriginal and Torres Strait Islander Safety and Promotion Strategy
National Falls Prevention for Older People Plan: 2004 Onwards
National Injury Prevention Strategies and Plans
National Injury Prevention and Safety Promotion Plan: 2004-2010
National Occupational Health and Safety Strategy 2002-2012
National Road Safety Action Plan 2007-2008
National Road Safety Strategy 2001-2010
National Water Safety Plan, 2004-2007
62
APPENDIX 3: Health promotion and risk reduction interventions across the continuum of care
Target General ‘well’ population Populations and individuals identified at Identified individuals with chronic
increased risk of chronic disease, falls disease or experiencing injury/falls
and other injury
Level of approach Population, community, group or Population, group and individual Individual and group approaches
individual approaches approaches
Nature of intervention Address determinants of health, wellbeing *Interventions targeting whole population Interventions that provide information/
and resiliency Identify high risk groups and individuals support to reduce risk factors in
Maximise healthy early development and provide information/support management of disease in individuals:
Promote healthy lifestyles and to reduce risk factors and reduce
development of disease: Screening for lifestyle risk factors
environments across the life course and
health care continuum*: Education about links between risk
Screening for lifestyle risk factors factors and optimal management of
eg. self-assessment, Lifescripts, Well injury/disease
Legislation and regulation of behaviour, Person’s Health Check, seniors’ falls
environments and products
eg. smoking restrictions, pool fences risk assessment Brief intervention to address risk
factors
Healthy public policy Screening for biomedical risk factors
eg. school canteen policy, eg. blood cholesterol, blood glucose Access & referral to appropriate
lifestyle modification services
Environmental support Education about diseases & links to eg. support groups, community
eg. access to cycle paths, healthy food, lifestyle risk factors facilities, allied health services, aged
safe playgrounds eg. media campaigns, publications care exercise programs
Community education & up-skilling Brief intervention to address risk Include lifestyle modification in self-
eg. anti smoking campaigns, education factors management programs
about links between risk factors and eg. smoking cessation, diet, alcohol
disease Health service systems and workforce
Access & referral to appropriate training
lifestyle modification services eg. support tools, information
Community strengthening/capacity eg. support groups, community
building
eg. community walking groups, local facilities, allied health, aged care
alcohol control action exercise programs
Workforce capacity development Health service systems and workforce

eg. Aboriginal health worker training training
in obesity prevention eg. support tools, information
*Interventions targeting whole
Research, monitoring and evaluation population
63
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Western Australian
Framework 2007-2011
HP10196 JUN’07 21939
Prepared by the Population Health Policy Branch

Health Policy and Clinical Reform Division
© Department of Health 2007

WA Health Promotion Strategic Framework 2007 2011

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WA Health Promotion Strategic Framework 2007 2011

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Western Australian

Health Promotion Strategic

HP10196 JUN’07 21939

Prepared by the Population Health Policy Branch

Healthy communities – increasing awareness of the social determinants of health and

Background and rationale 1

Background and rationale

The need for a Western Australian health promotion

About the Western Australian Health Promotion Strategic

Addressing the considerable health inequalities experienced by Aboriginal people is a high

The WA HPSF is underpinned by two key health promotion approaches:

1. Broadening the scope of health promotion

Figure 1: Prevention across the continuum of wellness and disease/injury

Population by stages of disease continuum

- Promotion of - Screening - Treatment and - Continuing Care

Prevent movement to Prevent progression to Prevent/delay

Adapted from Preventing Chronic Disease: A Strategic Framework, page 6[6]

2. A comprehensive approach to health promotion

Figure 2: Framework for comprehensive health promotion action

Populations Populations, groups and individuals Individuals

Infrastructure and Communication Health education Community Health care

The burden of chronic disease and injury in Western Australia

lost and years of life lost due to disability.

Figure 4: Burden of disease due to different injuries, WA, 2000[14]

Figure 5: Age-standardised hospital separation rates by Aboriginality, WA, 2005[12]

Figure 6: Age-standardised hospital separation rates by urban/rural, WA, 2005[12]

Determinants of chronic disease and injury

Early life and development of resilience

Factors influencing early life development and resilience include:

Social and environmental factors

Figure 7: Conceptual framework for determinants of health

General Socioeconomic Health Biomedical

Individual makeup: physical and psychological (genetics,

76% of children aged 5-12 years report insufficient physical activity[22].

Conditions Cardio- Type 2 Cancers Asthma Mental Arthritis Injury

4 Established risk factor + Association ? Possible risk factor

Savings possible from health promotion approaches

If Western Australia were to achieve a smoking prevalence of 10% by 2010, 1,290

Key strategic approaches

A mixture of population Emphasis on creating More systematic early Balance evidence-

Develop programs to Build sustainable A focus on shared Enhanced health

Types of interventions Priority population groups

Organisational implementation/ Outcomes

Key strategic approaches

1. A focus on shared behavioural risk factors for preventable chronic

2. Greater targeting of populations at most risk of harm to address health

3. Stronger partnerships to address the social and other determinants of health

In addition, health promotion programs addressing health behaviours need to[20]:

4. More integrated and comprehensive approaches

5. A mixture of population level and individual level approaches

6. Emphasis on creating environments that support healthy lifestyles and

7. Enhanced prevention throughout life, starting early

8. Enhanced health promotion for those identified at high risk of or with

9. More systematic early detection of increased risk of chronic disease

11. Build sustainable resources to support sustained effort

12. Balance evidence-based approaches with innovation and evaluation

13. Culturally appropriate approaches for Aboriginal people

Achieving a healthier and safer lifestyle

Low risk alcohol use

Enabling and implementation actions

Smoking prevalence reflects a strong social gradient, increasing as socioeconomic disadvantage

Groups with high levels of smoking include: