National Preventative Health Strategy – the roadmap for action

Reaching the targets we have set for Australia to become the healthiest nation in 2020 is ambitious but achievable. Each incremental step over the years to 2020 will need to be carefully monitored and built on to achieve the end goal, recognising that not all approaches can be introduced at once.

After nearly 60 years experience, we know what works in tobacco control. Comprehensive action across a number of strategies (for example, public education, taxation, legislation, regulation, rigorous monitoring, research and evaluation) has resulted in significant falls in smoking prevalence and changes in public attitudes to smoking.

We also have many years of experience in addressing alcohol problems, particularly drink driving, although there is still a long way to go to having a safer culture of drinking in Australia, including public perceptions of high-risk drinking and the secondary effects experienced by families and communities.

Tackling obesity is a comparatively new task. As part of the comprehensive approach proposed, it will be important to place a special emphasis on further building the evidence base so that the most cost-effective and efficient interventions are pursued systematically. In this area in particular, interventions will need to be staged over time. For example, some community-based obesity prevention programs will need to start as trials, underpinned by research and thorough evaluation, before being scaled across the country. Similarly, in areas such as the regulation of food advertising, an approach using responsive regulation is required, beginning with an evaluation of self-regulation, moving to co-regulation and independent regulation and legislation where stronger measures are required. This follows the cyclical ‘do, measure, report – do, measure, report’ approach to staged change and partnership approaches.

The figures below illustrate the progressive, determined and iterative processes, using multiple strategies over time, which has proved so successful for tobacco and road trauma.

Figure 1.4:

Milestones in reducing smoking in Australia 1980–2007

Source: The Cancer Council of Victoria 2009

Road fatalities in Australia 1968–2008

Source: Transport Accident Commission 2009

The Taskforce has identified seven critical strategic directions to be developed and implemented consistently and collectively for the National Preventative Health Strategy to be effective. Learnings from tobacco control and other prevention strategies show that addressing some strategies selectively but not others, or downgrading a strategy just as progress becomes apparent, will significantly reduce overall effectiveness.

To ensure the development of a comprehensive approach to prevention, the strategic directions are:

1. 
   Shared responsibility – developing strategic partnerships – at all levels of government, industry, business, unions, the non-government sector, research institutions and communities.
   
2. 
   Act early and throughout life – working with individuals, families and communities.
   
3. 
   Engage communities – act and engage with people where they live, work and play (for example, in the most relevant settings: home, school, workplaces and community). Inform, enable and support people to make healthy choices.
   
4. 
   Influence markets and develop connected and coherent policies – for example, through taxation, responsive regulation, and through coherent and connected policies.
   
5. 
   Reduce inequity through targeting disadvantage – especially low SES population groups.
   
6. 
   Indigenous Australians – contribute to ‘Close the Gap’
   
7. 
   Refocus primary healthcare towards prevention - one of the most important sectors of the health system for preventative health.
   

Health is a shared responsibility between those who will benefit from making healthy choices (for example, individuals, families and communities) and those who provide the infrastructure, services and support (governments at all levels, professional associations, the non-government sector, the research community, industry and business, and unions). Individuals, families and local communities are central to this shared approach. Effective prevention programs will depend on the participation of all Australian communities, at all levels – in the cities, in the bush and in the remote areas of the country. The figure below illustrates the range of players who contribute to preventative health.

Figure 1.6:

Working together

Australians as individuals will make prevention work. It is individuals who will take up regular physical exercise and make the right food choices for themselves and their families, who can voice a concern for public safety and an intolerance of drunken behaviour, and who can help make Australia a virtually smoke-free nation.

Individuals cannot achieve change on their own. They will need the support of employers and workplaces, unions, community leaders, industry, business and private sectors, the health services and all three levels of government.

Governments play a vital role in driving change and putting in place the support structures needed to achieve change.

Genuine and sustained partnerships between the three levels of government are essential if Australia is to achieve the targets described in this paper.

In broad terms:

• The Australian Government has responsibilities for policy and program implementation and coordination, across-government policy, fiscal incentives and regulation, the development of a strong evidence base and practice guidelines, monitoring and surveillance systems, and partnerships with national organisations, including employer and employee organisations and community agencies.

• State and territory governments have responsibilities for legislation and regulation in their own sphere, implementation and coordination of programs throughout the community, across-government policy, partnerships with local governments and state-based non-government organisations, and the monitoring and surveillance of the health of their population.

• Local governments have responsibility for local planning and support structures. They play a vital part in engaging local communities, and in providing some of the services, amenities and programs that prevent illness and promote good health.

For the three tiers of government to work well together, excellent coordination of the respective roles and responsibilities will be required, along with clear accountability for all their activities and outcomes.

‘A life-course perspective is essential for the prevention and control of non-communicable diseases. This approach starts with maternal health and prenatal nutrition, pregnancy outcomes, exclusive breastfeeding for six months, and child and adolescent health; reaches children at schools, adults at worksites and other settings, and the elderly; and encourages a healthy diet and regular physical activity from youth into old age.’[31]

The life course of individuals is shaped by their experiences in the earliest years of their life. The early childhood period has a profound impact on all aspects of development, and establishes the foundations of an individual’s future development. Early childhood experiences may place children on health and developmental pathways that are costly and difficult to change. Therefore, children necessarily form the cornerstone of any prevention agenda.

Research indicates that:

‘virtually every aspect of early human development, from the brain’s evolving circuitry to the child’s capacity for empathy, is affected by the environments and experiences that are encountered, in a cumulative fashion, beginning in the prenatal period and extending throughout the early childhood years’.[32]

In short, what happens to children at the earliest age has direct, identifiable outcomes in areas such as their health, life expectancy, the extent to which they rely on the economic and social support of the community and their capacity to contribute productively to their society. Children with poorer health do significantly less well in school, complete fewer years of education, and have significantly poorer health as well as lower earnings as adults.[33]

Investments in children’s health make significant differences not only to their health outcomes but also to a broad range of social, demographic and economic factors. There is strong evidence to show that investments that improve children’s health lead to higher cognitive development and school attainment, increased propensity for parents to invest in children, reduced cost of medical care and increased participation of parents in the labour market; all of which are associated with improved economic performance and stronger economic growth as well as reduced inequality in societies studied.[33]

‘…from conception, the early years of a child’s life influence health outcomes and life opportunities; an equitable start for all Australian children offers the best life chances for health and wellbeing in later years’ (Quote from submission)

The literature shows that ‘making greater investment in children’s health results in better educated and more productive adults, sets in motion favourable demographic changes, and shows that safeguarding health during childhood is more important than at any other age because poor health during children’s early years is likely to permanently impaired them over the course of their life’.[33]

The significance of these findings is reinforced by epidemiological evidence that adult disease can be linked to factors as early in the life course as foetal nutrition. Babies born with low birth weight, especially small for gestation age, are at increased risk of hypertension, dyslipidaemia, insulin resistance, type 2 diabetes, ischemic heart disease and breast or prostate cancer in adult life.[34-37]

The impact of poor nutrition during pregnancy (as indicated by low birth weight) can be compounded by ongoing poor nutrition and poor early childhood circumstances.[38] Studies have found that poor early childhood circumstances, including low income and family discord, interfere with healthy development

and lead to increased risks of onset of asthma, hypertension, diabetes, coronary heart disease and stroke or heart attack in adults, as well as significantly increased risk of poor mental health.[39] This same combination of conditions interferes with cognitive development and health capital in childhood, reduces educational attainment, and leads to worse labour market and health outcomes in adulthood.[40]

Figure 1.8:

Australia’s Performance Against UNICEF Benchmarks For Early Childhood Health

	Benchmark	Australia	Number of OECD countries which exceed / below benchmark
Infant mortality	< 4 per 1000 live births	5 per 1000 live births	10/15
Low birthweight	< 6% below 2500 g	6.4% below 2500 g	8/17
Immunisation 12-23 months	Average rate 95%	Average rate 92.7%	10/15

Source: Adapted from UNICEF, (2008) ‘The child care transition, Innocenti Report Card 8’. UNICEF Innocenti Centre, Florence.

While research has demonstrated that children’s life courses can be significantly disrupted by poor early childhood experiences, it is also demonstrated that high-quality preventative programs can substantially change this life course. Although no single program has been identified as a ‘magic bullet’, there is substantial evidence that by acting early governments are in a position to ameliorate the effects of poor quality environments and intervene in the intergenerational transmission of disadvantage.

In summarising this research,[42] the National Scientific Council on the Developing Child has identified a number of core principles, which they have labelled ‘effectiveness factors’. The first of these identifies that access to basic medical care for pregnant women and children can help prevent threats to healthy development as well as provide early diagnosis and appropriate management as problems emerge. Evidence supporting this factor includes the positive effects of adequate prenatal and early childhood nutrition on healthy brain development, and the developmental benefits for very young children when parental problems such as maternal depression are identified and treated effectively.

Similarly, there is extensive research to indicate that children’s participation in quality early childhood programs can make a substantial difference to cognitive and social outcomes. Longitudinal studies in the United States, following significantly disadvantaged families, have demonstrated substantial differences in

wellbeing, income, social participation and adjustment between adults who experienced high-quality early childhood programs compared to those who did not.[43]

Taken as a whole, the extensive research on early childhood gives Australia an excellent platform from which to reform and further develop its service systems for children and their families.

‘the importance of prevention for children, young people, their families and the broader community is now recognised and reflected in various policy initiatives around Australia’ (Quote from submission)

Australia has a clear opportunity to build on these initiatives and to create a service system which focuses on the health, learning and development of young children and which supports their families to provide the best possible environment to ensure their health and wellbeing. The Platforms program provides one example of a multi-strategy approach to such a service system.

Example: The Platforms program: CCCH Melbourne[45] • Community engagement and planning • Raising awareness of early child development through dissemination of research • Multi-disciplinary training for professionals who work with children and their families • Early identification of need through the development of a national tool and systematic application of checks at 18 months and three years of age • Provision of evidence-based information for parents • Evidence-based information accessible to communities, providing choices for interventions in a variety of settings • Collection of population data at community, state and national levels to inform sound policy decisions • A national monitoring and evaluation strategy to measure progress

Keeping older Australians healthy

‘Approach preventative health policy through a framework of a commitment to active ageing and the promotion of healthy lifestyles and interventions that enable older Australians to age well and in place’ (Quote from submission)

Population ageing is a common characteristic of many developed countries, including Australia, and is due mainly to a combination of decreasing fertility rates and increased life expectancy,[46] much of which is due to past successes in prevention. Australian men and women currently aged 65 can expect to live to 83 and 86 years, respectively.[2]

Life expectancy trends are anticipated to continue, with current population projections indicating that by 2036 the proportion of the Australian population aged over 65 years will have increased from 13% (2.7 million people) in 2006 to 24% or 6.3 million people.[47] This is also likely to result in changes to the profile of older Australians over the next 30 years and increase the degree of heterogeneity within this group. These include:

• Rapid increases in the number of Australians aged over 85 years (333,000 in 2006 rising to 1.1 million in 2036) and 100 years and over (just under 5000 rising to more than 25,000)[47]

• A shift in gender distribution, due to the life expectancy of Australian men improving at a faster rate than that of Australian women[47]

• By 2011 one in five older Australians aged over 70 will be from culturally and linguistically diverse backgrounds[48]

• An increase in the number of older Australians still actively engaged in the workforce[49]

• Almost half of women and a third of men aged 65 years will enter permanent residential care at some time in their remaining lives[50]

The anticipated changes to the number and profile of older Australians have the potential to significantly impact on the quality of life outcomes for this population group, presenting challenges to both government and the community.[51][52] Whilst some sections of the older population will maintain their health and activity levels well into their later years, others will face considerable problems related to their health and quality of life.

The increased prevalence of chronic disease as individuals age is one such consideration, with older members of the population likely to have more than one chronic health condition (51% of people aged 60+ years) as compared to younger individuals (12% of people aged 59 years and under).[53] Many conditions common in older age are associated with behavioural and biomedical risk factors such as obesity, alcohol misuse and tobacco consumption that can be modified to prevent the onset of chronic disease and consequently improve the quality of health outcomes through ‘healthy ageing’.[54]

Healthy ageing is ‘the process of optimising opportunities for physical, social and mental health to enable older people to take an active part in society without discrimination and to enjoy an independent and good quality of life’.[55]

While the potential scope for policy and action is diverse, efforts to tackle and improve healthy ageing have four key areas:[56]

• Improved integration in the economy and community

• Better lifestyles

• Adapting health systems to the needs of the elderly

• Attacking the underlying social and environmental factors affecting healthy ageing

Whilst all of these areas are important in ensuring healthy ageing is supported, the encouragement of better lifestyles amongst the older population has the largest potential for improving the health of the elderly.[56] There is a strong reliance on prevention, as it is never too early or too late to promote health.[57] Action to address obesity, alcohol misuse and tobacco consumption is vital in achieving good health outcomes.[53]