Women’s Health West Integrated health promotion plan 2013 – 2017

Women’s Health West – Integrated Health Promotion Plan 2013 -2017

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© Women’s Health West, 2013

Women’s Health West acknowledges the support of the Victorian Government

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Contents Women's Health West - An overview ……........................................................................ ……….4 Melbourne’s western metropolitan region ................................................................................... 4 Women’s Health West’s Strategic Plan 2012-2015...................................................................... 5 Strategic policy context .............................................................................................................. 5 Federal policy context ..................................................................................................... 5 State policy context ......................................................................................................... 6 Local policy context......................................................................................................... 7 Planning context: the Victorian Women’s Health Program .......................................................... 8 Regional Priorities ………………………….................................................................................... 9 Data informing the plan: Women in Melbourne’s west …………….................................................10 Conceptual frameworks that inform our approach ....................................................................... 10 Health promotion ..............................................................................................................11 Community development ................................................................................................. 11 Gender equity ................................................................................................................. 12 Human rights .................................................................................................................. 15 State priority: Promoting sexual and reproductive health Priority area: Promoting women’s sexual and reproductive health………….…………………………16 Definitions…………………………………..……………………………………………………………….…16 Evidence supporting sexual and reproductive health promotion as a WHW priority………………...16 Sexual and reproductive health promotion framework…...……………………………………………...17 Social determinants of women’s sexual and reproductive health………………………………………17 Poverty and socio-economic status …………………………………………...………………….17 Violence and coercion ………………………………………………………………………………18 Gender norms.………………………………………………………………………………………..19 Public policy and the law ……………………………………………………………………………20 Cultural norms………………………………………………………………………………………...20 Access to affordable, accurate and appropriate health services………………………………21 State priority: Promoting mental health Priority area: Promoting women’s mental health and wellbeing…………………………………..… 23 Definitions………………………………..………………………………………..……………………............ 23 Evidence support promoting mental health and wellbeing as a WHW priority...…………………... 24 Mental health and wellbeing frameworks…………………….………………………………..………….. 24 Social determinants of women’s mental health and wellbeing……………………………..…………...25 Social inclusion ………………………………..………………………………………………………25 Ethnic and race-based discrimination ………………………………..……………………………28 Access to economic resources and participation ………………………………..………………30 State priority: Promoting mental health – including prevention of violence against women Priority area: Prevention of violence against women………………………………………………….....33 Definitions…………………………………………………………………………………………………….. 33 Evidence supporting prevention of violence against women as a WHW priority…………………… 33 Primary prevention of violence against women framework…....……………………………………….. 34 Social determinants of violence against women…………….…..……………………………………….. 34 Adherence to rigid gender roles and stereotypes…………………..…………………………… 35 Unequal power relations between women and men…………………..……………………..…. 36 References…………………..……………………………………………………………………………......... 39

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Women's Health West - An overview Since 1988, Women’s Health West (WHW) has improved the health, safety and wellbeing of women in the western region of Melbourne through a combination of direct service delivery, research, health promotion, community development, capacity building and group work. Since 1994, WHW has delivered family violence services for women and children ranging from crisis outreach, court support, housing establishment and crisis accommodation options, to counselling and group work programs. WHW has been an active and strong supporter of family violence reform at a regional and statewide level, integrating and coordinating family violence services in our region, and promoting the integration of those services with a range of related sectors, including the housing sector. WHW’s health promotion, research and development arm offers a range of programs and projects targeted at prevention and early intervention strategies to improve outcomes for women's health, safety and wellbeing. WHW is a leader in the development of regional strategies, and views partnerships within and outside the health sector as crucial for bringing about effective and sustainable outcomes for women and children. These two main arms of the service place WHW in a unique position to work across all stages of the continuum - from primary prevention to early intervention to crisis response - and support women to take control over their decisions and their lives.

Melbourne’s western metropolitan region WHW services Melbourne’s western metropolitan sub-region. The catchment extends west in an expansive ‘wedge’ from Melbourne’s inner suburbs to meet the rural fringe of the metropolitan border, comprising the seven local government areas (LGAs) of Brimbank, Hobsons Bay, Maribyrnong, Melbourne, Melton, Moonee Valley and Wyndham. Melbourne’s west is a diverse and growing region. It has two of the ten LGAs identified with Australia’s largest population growth in 2010-12, and the cities of Wyndham and Melton are ranked second and seventh respectively in relation to Australia’s highest population growth (Department of Planning and Community Development, 2012). The west is also home to two of Melbourne’s four designated ‘growth corridors’, where population growth is forecast to increase by 42.1 per cent by 2022 (Department of Health, 2011a). This rapid growth exerts enormous pressure on planning, infrastructure and program and service provision. WHW characterise our catchment in terms of a gentrified inner area with pockets of public housing, entrenched disadvantage in the middle area, and consistent growth in the outer area. Our plans recognise and respond to this complexity. The Index of Relative Socio-economic Disadvantage indicates the high burden of ill health and disadvantage experienced by communities in Melbourne’s west. The top ten most disadvantaged LGAs in metropolitan Melbourne include four western region municipalities - Brimbank (ranked second), Maribyrnong (ranked fourth), Melton (ranked ninth) and Hobsons Bay (ranked tenth). In fact, all seven of the western region’s LGAs are named in the top 17 most disadvantaged municipalities in metropolitan Melbourne. The west is a culturally diverse and vibrant region. Residents speak more than 100 languages and it has long been a settlement area for refugees, including those from South-East Asia, the Horn of Africa and Southeast Europe. The 2011 Census data indicates that 37 per cent of female residents Women’s Health West – Integrated Health Promotion Plan 2013 -2017

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in the western region of Melbourne were born overseas, which is notably higher than the Victorian average of 26.4 per cent (WHW, 2013). The region is home to 29 per cent of Melbourne’s Indigenous population and has a higher than state-average population of women living with a disability (WHW, 2013). Many women in our region experience intersectional discrimination as the ‘consequences of the interaction between two or more forms of discrimination’ (United Nations, 2000: 2) due to their race, ethnicity, religion, ability, sexuality or socio-economic status. WHW’s health promotion program engages a health equity approach and, as such, works to reduce and prevent poor health outcomes among women and girls who experience the most significant disadvantage.

Women’s Health West’s Strategic Plan 2012-2015 WHW’s Strategic Plan 2012-2015 and its vision, mission and goals both inform and provide the planning context for our integrated health promotion plan. WHW’s vision is ‘equity and justice for women in the west.’ We aim to achieve this through our mission of ‘working together for change – by supporting women and their children to lead safe and healthy lives, and changing the conditions that cause and maintain inequity and injustice.’ As a strategic-thinking organisation, we have designed the plan to ensure the chosen priorities meet current and future need. The governance and the operations of the organisation enact our five strategic goals. These are:






Delivering and advocating for accessible and culturally appropriate services and resources for women and their children Improving the conditions in which women live, work and play in the western region of Melbourne Putting women’s health, safety and wellbeing on the political agenda to improve the status of women Recognising that good health, safety and wellbeing begins in our workplace Working with others to achieve our goals

The process used to develop WHW’s Strategic Plan 2012-2015 included a review of relevant national and state government policy, funding guidelines, community health and municipal public health and wellbeing plans, and regional data collection and analysis. It also involved consultations with community women, partner organisations and other communities of interest, WHW staff, and our board of directors. This process and its findings inform the integrated health promotion priorities outlined in this plan.

Strategic policy context The WHW Integrated Health Promotion Plan 2013-2017 and our three priority areas of promoting sexual and reproductive health, mental health and wellbeing and prevention of violence against women are strategically aligned and leverage off federal, state and local policy frameworks. This approach ensures that our integrated health promotion plan supports the current policy agenda, and that our program is tailored to the unique characteristics and demographics of Melbourne’s west.

Federal policy context WHW’s integrated health promotion plan is guided by a suite of federal policy frameworks that directly impact on our work. Most notably, the National Health Reform Agreement (2011) outlines a stronger primary healthcare system supported by joint planning with states and territories. At the Women’s Health West – Integrated Health Promotion Plan 2013 -2017

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local level, this reform saw the introduction of three Medicare Locals in Melbourne’s western metropolitan region – Inner North West Melbourne, Macedon Ranges and North Western Melbourne, and South West Melbourne. WHW deems Medicare Locals to be a key strategic partner in the delivery of programs and services that are accessible and responsive to the diversity of women across our catchment. The National Women’s Health Policy (2010) adopts a dual policy approach that recognises the importance of redressing immediate and future health concerns, while challenging structural inequities that impact on women’s health and wellbeing. WHW’s integrated health promotion plan shares two of the national women’s health priorities - sexual and reproductive health and mental health and wellbeing. These two health priorities are also a focus of efforts underway by the National Prevention Health Agency (Commonwealth of Australia, 2011). The Council of Australian Governments’ (COAG) commitment to mental health reform outlined in The Roadmap for Mental Health Reform 2012-2022 will shape our work into the future. The significant social policy reform of the National Disability Insurance Scheme is also a key strategic focus for WHW, specifically as it relates to our Home and Community Care (HACC) program and efforts to ensure positive health and wellbeing outcomes for women with a disability in Melbourne’s west. The National Plan to Reduce Violence against Women and their Children 2010-2022 is the first plan that aims to reduce violence against women through coordinated action across Australia. WHW’s primary prevention strategies directly align with our intended outcomes for plan, most notably the WHW You, Me and Us respectful relationships program, which is funded by the former federal government’s Department of Families, Housing, Community Services and Indigenous Affairs.

State policy context WHW’s integrated health promotion plan leverages off the Victorian Health Priorities Framework 2012-2022: Metropolitan Health Plan, particularly the outcomes, principles and reform priorities for system improvements that focus on women (Department of Health, 2011b). Our plan’s priorities, strategic activities and partnerships are also strongly influenced by and aligned with the state government’s Victorian Public Health and Wellbeing Plan 2011-2015. In keeping with this policy framework, WHW will work to promote sexual and reproductive health and mental health as two of the nine state priorities for ‘keeping people well’ (Department of Health, 2011c: 69). We will achieve this through the provision of information and support to improve health literacy and tailored interventions to optimise the health of specific population groups of women in the west (Department of Health, 2011c). Prevention of chronic disease and maintenance of health is a strong focus of both the Victorian Health Priorities Framework 2012-2022 and the Victorian Public Health and Wellbeing Plan. In light of this, and the high and growing prevalence of chronic disease among women in Melbourne’s west, our four-year plan now incorporates health promotion actions designed to reduce the incidence of diabetes. We will do this by supporting a gender-sensitive approach to diabetes prevention, public health planning, and program and service delivery that accounts for the complex causality and multiple social and behavioural risk factors that disproportionately cause diabetes among certain groups of women. In 2012, as part of the COAG agreement, the state government developed a four-year plan, Victoria’s Action Plan to Address Violence against Women and Children: Everyone has a Responsibility to Act, which works across the continuum from primary prevention to tertiary Women’s Health West – Integrated Health Promotion Plan 2013 -2017

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response. WHW’s primary prevention strategies Preventing Violence Together (which uses Department of Health funds) and United (funded by the Department of Justice) further the strategic objectives of this plan to create gender equitable organisations, communities, and cultures. As part of the Victorian women’s health program and a member of the Women’s Health Association of Victoria (WHAV), WHW’s health promotion priorities contribute to a strategic and coordinated statewide approach to improving women’s health, safety and wellbeing. Evidence suggests that when disadvantaged women have access to women’s health services, and when those services work in close collaboration to share skills, knowledge and resources their health outcomes are greatly improved. In response to this evidence, WHAV engaged in a rigorous strategic planning process that resulted in the 10 Point Plan for Victorian Women’s Health: 2010-2014, which is currently being updated. The women’s health services that form WHAV have undertaken strategic planning and priority setting for the 2013-17 funding period in close collaboration with the Department of Health. As a result of this work, WHW shares its health promotion priorities with other regional and statewide women’s health services. This approach ensures women’s health, safety and wellbeing is improved across Victoria, with strategies for improvement tailored to the different needs of different groups of women arising out of the particular demographics of each region.

Local policy context WHW has fostered long-term partnerships with other organisations in our region to align our integrated health promotion plan and priorities effectively. WHW leads two western region primary prevention priorities in the areas of sexual and reproductive ill health, and violence against women. Our regional approach strengthens collaboration across a range of sectors and settings, using a mix of health promotion interventions and capacity building strategies to optimise the health, safety and wellbeing of women in the west. WHW successfully employs these formalised partnerships across two priority areas to support the implementation of primary prevention frameworks, share resources and knowledge, and integrate regional health promotion action. The two primary care partnerships that service the western region catchment – Inner North West and HealthWest – highlight prevention of violence against women as an integrated health promotion priority. Similarly, all seven local governments in the west have incorporated prevention of violence against women as a priority in their council strategies, including their municipal public health and wellbeing plans (MPHWP). Three local governments have now identified sexual and reproductive health promotion actions in their MPHWP plans as well. In 2012 the Department of Health amended the funding cycle for agencies receiving integrated health promotion funds to align with the municipal public health and wellbeing planning cycle. This amendment recognises the crucial importance of agencies including local government being involved in population health planning, and as such, we have built this planning cycle into this plan.

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Systems change to ensure effective women’s health and wellbeing outcomes Ensure the diverse experiences of women in the region are represented in policy and planning Objective processes at the local, state and federal levels. A strategic response to social policy and legislative reform is widely recognised as an important Social and health promotion action to promote women’s health, safety and wellbeing. As a regional behavioural women’s health service with strong partnerships with community women and local service determinants providers, WHW is ideally placed to influence and advise on social policy and law reform and the impact it will have at a local level. Population target Women in Melbourne’s west, with specific attention to women who experience social exclusion, group discrimination and violence. Program partners include regional and local services, including community health, local government, primary care partnerships, medicare locals and other organisations that work in Program partners the west. WHW also partners with statewide women’s health services and the women’s health sector to influence state and federal policy and law reform to ensure optimal health outcomes for women in the west. WHW writes policy and law reform submissions related to our health promotion and direct service priorities. WHW also produces a publically available quarterly Environmental Policy Scan that provides an analysis on the latest developments in policy and law reform at a local, Health promotion state and national level. The aim of the scan is to resource WHW staff and partners to actions and settings understand the localised impact of the changing policy and legislative environment. We also partner with the women’s health sector to undertake Safe, Well and Connected, a package which is designed to support newly elected councils integrate women’s health and wellbeing priorities into their municipal public health and wellbeing plans. WHW evaluates this work by assessing the number of recommendations set out in WHW policy Evaluation submissions that are implemented within government policies and legislative reform.

Planning context: the Victorian Women’s Health Program WHW’s health promotion department work is in line with the Department of Health’s guidelines for the Victorian Women’s Health Program, at a systems level and through direct project work with women and their communities to improve women’s health, safety and wellbeing. System change involves influencing, advising and working with local government and the community and health sector to effectively respond to women’s health needs (Department of Health, 2013b). As articulated in the Department of Health guidelines (2013), WHW’s health promotion program will:






Analyse statewide and local data and other information sources to identify service gaps and to inform planning and service responsiveness for women’s health Research, distribute existing information, develop new resources, apply a gender analysis and support new research in women’s health to increase knowledge and have a positive effect on health policy and programs Facilitate understanding and inclusion in planning and service documents of local government, other government agencies and health service providers of actions to redress women’s health needs and barriers to service access

Our direct project work involves strong partnerships and collaboration with women and communities. As such, WHW’s health promotion program will:



Develop and provide information to women and support for behavioural and attitudinal change to manage their health through mechanisms such as health literacy Identify, implement and evaluate evidence-based preventative health approaches and resources for improving women’s health and wellbeing

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Translate evidence to the local context and work with partners to ensure the implementation of evidence-based, preventive health interventions for women, particularly those who experience disadvantage (Department of Health, 2013b)

Project descriptors under each priority area demonstrate how our program works to achieve systems change and direct health promotion activities with community women and girls to improve their health and wellbeing status.

Regional priorities The Department of Health is instrumental in influencing the local policy context. The Department of Health’s North West Metropolitan Region office has a strong focus on the social determinants of health, evident by the regional management forum (RMF) priorities of employment, education, transport and housing. This reflects the growing recognition that work designed to redress the social determinants of health is critical to a reduction in health inequities at a local level. WHW recognises that employment is a key pathway for social inclusion and women’s civic, economic and social participation. A significant proportion of women in the west are engaged in part-time employment or not in the labour force at all (WHW, 2013). In Australia, women are overrepresented in non-career focused part-time and casual employment, which is often low paid and provides few opportunities for training, development and career progression (Department of Commerce, 2012). In 2013, WHW’s family violence arm began a project with partners in the west to mentor young women who have experienced family violence, homelessness and mental illness in order to redress barriers to employment. The project will provide women with opportunities to identify aspirations, be aware of possible pathways and careers, gain skills required to participate in the work place, identify and apply for employment and maintain work. WHW health promotion arm will leverage off this project and its partnerships to undertake a race-based discrimination project in settings that include workplaces. Evidence suggests that race-based discrimination in the workplace is increasing and that many Muslim women, particularly those who wear a veil, experience significant difficulties finding and maintaining suitable employment (VicHealth, 2012a; Syed and Pio, 2010). WHW is committed to action on the RMF priorities by way of a project designed to reduce and ultimately prevent race-based discrimination in settings including the workplace. WHW as a provider of family violence services also has a focus on housing, as this is a critical factor for women who experience family violence and are considering or have left a violent relationship. One in every two women with children seeking homelessness services in Victoria is escaping violence (Council for Homeless Persons, 2012). The displacement caused by homelessness arising from family violence increases experiences of trauma and can also limit labor force participation which affects women’s ability to generate independent financial resources to gain and sustain housing. WHW family violence and health promotion arms are committed to the RMF priority of housing and will undertake a range of activities to address the barriers women face when leaving a violent relationship. WHW will also support action on the RMF priorities through the development of a series of resources for local government, the community and health sectors, among others. The resources will support organisations to undertake a gender analysis for policy, service and program planning that considers how the social determinants of health intersect with gender to produce different and most often inequitable health outcomes for women when compared to men. The resources will

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further strengthen public health planning, program and service delivery that is responsive to, and respectful of, women’s specific health and wellbeing needs.

Data informing the plan: Women in Melbourne’s west A gender-sensitive approach to the development and implementation of policies, programs and services requires an understanding of the barriers women face and their unique experiences of health and wellbeing. WHW’s Women in Melbourne’s West: Sex-disaggregated data and gender analysis for service and program planning (2013) is an important tool that informs the development of our integrated health promotion plan. The report contains statistical information drawn from a range of demographic and health status data sources and provides a comprehensive profile of the health, safety and wellbeing of women living in the western region. This sex-disaggregated data and gender analysis on the social determinants of health, includes education, housing, socioeconomic and employment status, public transport and income. It also contains data on specific groups of women who, due to discrimination and marginalisation attributed to their race, ethnicity and ability, are more vulnerable to poor health outcomes. This report has built the evidence-base to support the prioritisation of our integrated health promotion priorities. Supporting local action on the social determinants of women’s health and wellbeing Improve women’s health, safety and wellbeing by influencing, advising and working with Objective regional and statewide partners who work in Melbourne’s west to respond effectively to the social determinants of women’s health. Health and community services in Melbourne’s western region are increasingly working to Social and respond to the social determinants of health. WHW plays an important role in analysing local behavioural data and research to support other organisations to adopt a gender-sensitive approach to determinants municipal public health planning, policy development, and program and service provision. To increase the health and wellbeing outcomes for women who work, live or play in Population target Melbourne’s west, particularly those who experience multiple and intersecting forms of group discrimination and disadvantage. Project partners include community health agencies, local government, primary care Program partners partnerships, medicare locals and other organisations that work in Melbourne’s west. Our work in this area will occur across multiple sectors and settings. WHW supports organisations in the west to use sex-disaggregated data and apply a gender analysis to inform Health promotion planning and programs that are responsive to women’s health. This work will also advise actions and settings organisations taking action on the RMF priorities to understand how housing, employment, transport and education intersect with gender to produce poorer health outcomes for women. WHW will evaluate this work by assessing organisational use of sex-disaggregated data and Evaluation application of a gender analysis in municipal public health planning, policy development, and program and service provision in the west.

Conceptual frameworks that inform our approach Premised on a social model of health, WHW’s work examines factors beyond women’s individual or biological disposition to recognise the effect of social, economic, cultural and political factors and conditions on health and wellbeing. This conceptual framework for improving health outcomes aims to prevent and reduce illness by locating health in its broadest context and identifying and redressing structural factors that cause and maintain inequity. Health is therefore defined as 'a complete state of physical, mental and social wellbeing, not merely the absence of disease or infirmity' (World Health Organisation, 1986). Informed by these notions, the main conceptual frameworks WHW use to identify our health promotion priorities, target groups and activities are human rights, health promotion, community development and gender equity.

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Health promotion In 1986, the Ottawa Charter was successful in challenging dominant health promotion frameworks that had focused on biomedical interventions, individual risk factors and lifestyle behaviours to the exclusion of social and economic determinants of health. Health promotion not only embraces actions directed at increasing the skills and capabilities of individuals, but also action directed towards changing social, environmental and economic conditions that impact on health (WHO, 1986). The charter insists that health promotion must focus: on achieving equity in health. Health promotion action aims at reducing differences in current health status and ensuring equal opportunities and resources to enable all people to achieve their fullest health potential (WHO, 1986: 1). The charter’s call for sectors outside of health to take action on the social structures and conditions that perpetuate health inequities continues to inform contemporary health promotion practice (Keleher, 2004). In 2008, the World Health Organisation’s (2008) Closing the gap in a generation report outlined important evidence on the social determinants of health and stated that the dramatic health inequities within and between countries are caused by the unequal and unfair distribution of power, income, resources and social benefits. This report took an important step forward in international health discourse by naming gender equity as a social determinant of health, a position that WHW strongly supports and continues to action throughout all its health promotion activities (Commission on the Social Determinants of Health, 2008). Available evidence on the cost of Australia’s inaction on the social determinants of health provides a clear impetus to act. A recent report commissioned by Catholic Health Australia (2012) highlights the cost benefits of adopting the World Health Organisation’s (2008) recommendations, which include:







500,000 fewer Australians suffering chronic illness 170,000 extra people entering the workforce, generating $8 billion in earnings $4 billion annual savings in welfare support payments 60,000 fewer people hospitalised annually, saving $2.3 billion in hospital expenditure 5.5 million fewer Medicare services each year, saving $273 million, and 5.3 million fewer Pharmaceutical Benefits Scheme scripts filled each year, saving $185.4 million (Brown et al, 2012).

This health economics argument for adopting a social determinants approach is persuasive and outlines the importance of investing in primary prevention efforts. WHW deems it equally important to recognise that women and children are entitled to opportunities and resources that advance their wellbeing, as health is a fundamental human right.

Community development Community development is founded on a conscious recognition and response to the ways that structural power influences all aspects of people's lives, while recognising that people still possess agency within these structures (WHW, 2010). A community development framework challenges women to identify and mobilise their agency and to find ways to contest power and its effects, in order to increase control over their lives (Nussbaum and Glover, 1995). Research shows that a community development approach that seeks to change systems, rather than people, holds the Women’s Health West – Integrated Health Promotion Plan 2013 -2017

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greatest potential to bring about sustained improvements for community health and wellbeing (Nussbaum and Glover, 1995). A community development framework suggests that action in relation to women’s health must be responsive to the local context and continuously engage with women’s stories and lived experiences. Community development frameworks must also recognise the very real barriers and challenges facing women, while at the same time encouraging sustainable actions that support communities to determine meaningful outcomes (Nussbaum and Glover, 1995). Community development can complement health promotion strategies by highlighting the importance of community involvement in bringing about change. WHW works within a community development framework that assists women – collectively and individually – to identify and build on their skills and experience and to take action that will lead to improved health and social outcomes. WHW recognise that this process of organising, skill sharing, and women building new networks and connections is as important an outcome as the initial strategy; with social connectedness and inclusion identified as a protective factor for women’s health and wellbeing.

Gender equity Gender equity frameworks are central to WHW’s approach. Gender equity is an important social justice goal and is the process of being fair to women and men through the recognition of diversity and disadvantage, and redirecting resources and services towards those most in need to ensure equal outcomes for all members of the community (WHW, 2010). Gender equity frameworks recognise that socially constructed gender roles and responsibilities play an important part in shaping life choices, experiences and circumstances (WHW, 2010). Work centred on gender equity frameworks identifies and works to redress the structures in society that create privilege and power for men and boys relative to women and girls. They also recognise that gender stereotypes are central to much of the disadvantage experienced by women and girls. Gender inequity also greatly influences the ways that women experience health, ill health and the health system, and as such, is recognised as an important social determinant of health (WHO, 2011). Gender inequity is reflected in the discriminatory values, norms and practices that produce specific health concerns, such as violence against women. Gender inequity is apparent in the differential exposure and vulnerability to disease, disability and injury associated with higher rates of poverty and material inequity among women. Gender inequity underlies the continued support of health systems and research that undervalue and underfund health areas specific to women (WHO, 2011). Gender equity frameworks exist, in part, to ensure that structural factors in women's health are understood to have gendered dimensions, and that responses take women's social position into account. Gender equity frameworks acknowledge differences among women due to race, ethnicity, religion, sexuality, ability and socio-economic status and the complex effect this has on health and wellbeing. WHW’s health promotion program is designed to be responsive to women who experience the greatest disadvantage in Melbourne’s west. Workforce Development Promote workplace health and wellbeing by investing in whole-of-organisation initiatives that Objective support good practice at WHW that improves client and community health outcomes. Social and Working in a Feminist Organisational: An Audit highlights employment as an important social behavioural determinant of women’s health and wellbeing. This initiative ensures that our workplace culture Women’s Health West – Integrated Health Promotion Plan 2013 -2017

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determinants and processes align with our core principles, are supportive and sustainable, and encourage staff to translate this into their work with clients, communities and organisations. Population target WHW has designed this project to improve outcomes for client and community women who group access our services and programs. This is a whole of organisation initiative whose strategies apply to WHW’s Board of Directors, Program partners senior management and staff. The audit tool is also publically available for use by other women’s health services. This project measures where WHW is already embedding gender equity principles within organisational policy and practice and assesses areas of feminist theory, practice, processes Health promotion and behaviours that we need to strengthen. WHW will use the findings of the audit to drive actions and settings internal actions to strengthen our strategic goals in relation to how we work as an organisation, with clients and community women, as managers, in teams and our individual responsibility for building an equitable workplace culture. WHW will evaluate the project using staff surveys, focus groups, data collated at our cross Evaluation team training, and data sourced from our annual organisational audit. The following table sets out the matrix of critical questions we use to plan our projects; questions are based on the health promotion, community development, and gender equity frameworks described above.

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Planning for Equity Framework (2008) Health promotion

Community Development

Gender Equity

What are the social determinants of the health topic you are focusing on? What evidence is available to support your contention?

How do these problems affect this particular community? How do you know this?

What is the specific impact of gender (or other) inequality on this aspect of women’s health? How do you know this?

Which particular population group are you working with and why did you choose this group?

How do you plan to involve the community you are working with in this project? What about this community might make it difficult to bring about change and how might you overcome this? What are the existing potentials/resources/ strengths within this community and how can they best be deployed?

What are the nuances of culture, class, ability, sexuality, ethnicity, etc that also affect the women you are targeting and what might you need to take into account to respect these differences?

Which particular setting(s) are you targeting? Why?

How will you ensure that people in communities can contribute to planning, decision-making and evaluation of health services and other settings? How will you make links between the different sites of action required to make change?

How will this work affect women’s gendered experience of health, ill health and health systems? Will the activity assist those settings to consider gender in their planning, delivery and evaluation of services, policies, etc?

What types of health promotion action will you undertake and why did you choose these activities?

How will your actions help to organise the community - build the skills, processes, networks and strategies required to mobilise community action - encourage self-determination over priorities and outcomes, and sustain networks and connections? Are your planned actions realistic and do they appropriately identify the challenges to action?

Have you framed your actions and responses in ways that take women’s social position into account and thus their power and capacity to be active in their communities? Will it create opportunities for women to develop new skills, ideas and approaches and validate gendered-female ways of working?

What do you hope will be the impact of your project in the short to medium term? - Individual - Organisational - Community - Society

Are your goals and objectives realistic for this community at this time? Explain why. How will you gauge success?

Do your goals and objectives have gendered dimensions. Will your project change attitudes or ways of working that impede women’s power and capacities to be active in their communities?

What sorts of changes do you hope to see in the long term because of your project? - Individual - Organisational - Community - Society

Do the outcomes of your project help to decrease the factors that restrict this community’s power to influence and participate? How will you gauge this?

Will your outcomes contribute to improving women’s equality?

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Human rights Human rights form crucial components of health promotion, gender equity and community development, and underpin all of these frameworks. The ‘right to health’, first set out in the United Nations Universal Declaration of Human Rights (1948) establishes fundamental freedoms and entitlements, including the right to control one’s health and body, the right to participate in decisions about one’s health, and the right to freedom from violence, non-consensual medical treatment and experimentation. Importantly for the women’s health sector, these are rights that have been systematically denied to women. WHW works to redress the historic and continuing gender inequities that violate women’s rights to health, bodily integrity and that limit their ability to participate in Australian society. By calling for action across a spectrum of social, cultural, political and economic indicators, human rights frameworks also provide strong support for a social determinants approach to health (WHV, 2009). The United Nations Convention on the Elimination of All forms of Discrimination Against Women (CEDAW, 1979) a foundational instrument for women’s rights, affirms women's rights to non-discrimination in education, employment, and economic and social activities. CEDAW acknowledges that prejudice and restrictive gender stereotypes produce and maintain power structure within society that undermine women’s health, and provides a framework for challenging the status quo. International, national and state human rights legislative frameworks inform WHW’s health promotion projects. For example, WHW has worked for more than a decade to prevent and respond to female genital mutilation/cutting (FGM/C), which is internationally and nationally recognised as a gender-based human rights violation that affects women and girls. Our Family and Reproductive Rights Education Program works to prevent FGM/C as part of our integrated and coordinated approach to sexual and reproductive health policy, program and service delivery. Action to prevent FGM/C must be multifaceted, engage practising communities in their local area and encourage sustainable actions that lead to communities taking control of, and responsibility for, the elimination of the practice. WHW works with partner organisations and affected women and their communities in the west to deliver primary prevention programs and ensure culturally inclusive and clinically appropriate service provision for women and girls affected by FGM/C. Similarly, the Victorian Charter of Human Rights and Responsibilities (2006) has enabled an environment in Victoria that is conducive to the development of education resources, programs and initiatives. WHW’s Our Community, Our Rights project is designed to translate human rights into practical and accessible knowledge and skills for refugee and migrant women in Melbourne’s west.

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State priority: Promoting sexual and reproductive health Priority area: Promoting women’s sexual and reproductive health Sexual and reproductive health, like other areas of health, is influenced by a number of factors including a complex interplay of biological, psychological and social determinants (O’Rourke, 2008). While these factors impact upon men and women’s sexual and reproductive health, it is women and girls who bear the overwhelming burden of sexual and reproductive morbidity (Hunt and Bueno de Mesquita, 2010). In Victoria the burden of disease associated with sexual and reproductive ill health continues to rise despite concerted efforts over the past decade (Department of Health, 2011c).

Definitions WHW’s sexual and reproductive health promotion program is underpinned by the following internationally recognised definitions: The World Health Organisation defines sexual health as: a state of physical, emotional, mental and social wellbeing in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, sexual rights of all persons must be respected, protected and fulfilled (WHO, 2006: 4). The World Health Organisation defines reproductive health as: a state of complete physical, mental and social wellbeing … in all matters relating to the reproductive system and its functions and processes. Reproductive health therefore implies that people are able to have a responsible, satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how to do so (WHO, 2006: 4). Reproductive rights are defined as: the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so and the right to attain the highest standard of sexual and reproductive health. (WHO, 2006:4).

Evidence supporting sexual and reproductive health promotion as a WHW priority Women and girls who reside in Melbourne’s western region fare worse on a range of sexual and reproductive health indicators compared with the Victorian state average. These include:


High rates of teenage pregnancy; the west is home to 13 per cent of Victoria’s teenage parents. Motherhood in the teenage years is associated with an increased risk of poor social, economic and health outcomes (DEECD, 2009)

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High prevalence of women incarcerated in one of Victoria’s two women’s prisons in the region, and 82 per cent of Victoria’s female prison population (Department of Justice, 2013) A 21 per cent increase in chlamydia notifications in the region between 2010 and 2012 (Department of Health, 2013a). Chlamydia is often asymptomatic in women and if untreated has severe implications for sexual, reproductive and maternal health, and is the main preventable cause of women’s infertility (WHO, 2010a) The pap screening rate for women aged 20-69 years is a concerning 53.1 per cent, which is lower than the Victorian state average of 60.8 per cent (Victoria Cervical Cytology Registry, 2010) Twenty legal brothels and an emerging street sex trade in Footscray, which is associated with drug dependence, injecting drug use and increased rates of men’s violence against women (Rowe, 2011) Only 53 per cent of sexually active young people in the region practice safe sex by using a condom, which is lower than the reported Victorian rate of 58 per cent (DEECD, 2011).

Sexual and reproductive health promotion framework WHW’s Sexual and Reproductive Health Promotion Framework (2011) provides the overarching conceptual guide for our sexual and reproductive health promotion program, as well as integrated action across the west through the regional plan, Action for Equity. The framework comprises five layers of influence and recognises that opportunities to prevent sexual and reproductive health morbidity are most effective when a range of coordinated, mutually reinforcing health promotion actions occur across settings and sectors (VicHealth, 2007). Evidence also shows that, to be effective, sustainable and equitable strategies must work to redress the six social determinants of sexual and reproductive health (WHO, 2010a; Taylor, 2011). Action for Equity: A Sexual and Reproductive Health Plan for Melbourne’s West 2013-2017 Lead and coordinate a regional sexual and reproductive health promotion plan to increase Objective integration and coordination across Melbourne’s west. Social and Action for Equity is Victoria’s first regional sexual and reproductive health promotion plan. behavioural Informed by a primary prevention approach, the plan is designed to prevent ill health by determinants working to redress the six social determinants of sexual and reproductive health. The plan has a range of interventions designed to improve the sexual and reproductive health Population target status of young people, Aboriginal and Torres Strait Islanders, women, migrants and group refugees, gay, lesbian, transgendered and intersex people, those living with a disability, people in or being released from prison, sex workers, and injecting drug users. Led by WHW, partners comprise community and women’s health, local government, ethnoProgram partners specific and Aboriginal community-controlled organisations, a primary care partnership, a hospital, and specialist sexual and reproductive health services. The plan operationalises WHW’s Sexual and Reproductive Health Promotion Framework Health promotion (2011) and has 13 objectives that strengthen collaboration across a range of sectors and actions and settings settings, using a mix of health promotion interventions and capacity building strategies. Evaluation Action for Equity is underpinned by a rigorous evaluation strategy that will involve process, impact and outcome evaluation.

Social determinants of women’s sexual and reproductive health Poverty and socio-economic status The relationship between poverty as both a cause and outcome of poor sexual and reproductive health is well established in the public health field (Channon, Falkingham and Matthews, 2010). Low socio-economic status ‘limits access to material and psychosocial resources and affects individuals’ ability to exercise autonomy and decision-making’ (VicHealth, 2005:7) all of which are fundamental to women’s optimal sexual and reproductive health. Women’s Health West – Integrated Health Promotion Plan 2013 -2017

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Poverty affects women’s ability to access health services, contraception, abortion, and timely screening and treatment for sexually transmitted infections (WHO, 2010a). For example, Victorian research conducted by Doreen Rosenthal and her colleagues (2009) shows that poverty influences women’s reproductive choices and decisions about childbearing (Rosenthal, 2009). Women experiencing socio-economic disadvantage are also less likely to use preventive and curative sexual and reproductive health services than women from higher income brackets, including antenatal care and preventive screening (WHO, 2010a).

Violence and coercion A considerable body of research shows that violence against women is associated with immediate and long-term sexual and reproductive health consequences (WHO, 2010a). A large body of research shows that women who have experienced sexual assault are at increased risk of contracting sexually transmissible infections and a range of gynaecological problems (Eby, 1995). Sexual assault has also been linked to a range of subsequent high-risk behaviours including unsafe sexual practices, excessive alcohol consumption and illicit drug use (de Visser et al, 2007). Australian and international research has consistently shown an emphatic association between partner violence and abortion indicating that efforts to prevent intimate partner violence can reduce the rate of unwanted pregnancy (WHO, 2010a; Taft and Watson, 2007). An Australian longitudinal study found that young women experiencing violence from their partner were three times more likely to terminate a pregnancy than young women who were not a victim of violence (Taft and Watson, 2007). Women subjected to intimate partner violence during pregnancy are also more likely to experience miscarriage, low birth weight, preterm births or foetal death than women who live free from violence (WHO, 2010a). Hence, WHW’s violence against women primary prevention strategies are crucial to optimise women’s sexual and reproductive health and reduce health inequity. Exploring women’s experiences in the unregulated street sex worker industry Undertake research with women in the western region sex industry to inform health promotion Objective actions designed to increase sexual health, social inclusion and freedom from discrimination. Research shows that women who work in the unregulated sex industry experience high rates Social and of violence and sexual assault, discrimination and marginalisation. The emergence of an behavioural opportunistic street sex worker industry in Footscray and the surrounding suburbs has determinants prompted WHW to undertake a research project to explore the human rights, health and wellbeing status of female street sex workers in the region. Population target The research project will look to recruit twenty-five women who work or who have previously group worked in the street sex worker community in Melbourne’s outer west. WHW will partner with women who have worked in the sex industry, organisations that work Program partners primarily with sex workers, health and community sector, relevant local governments and Victoria Police to ensure the recommendations are appropriate. Health promotion WHW will undertake an action research project to investigate the experiences of street sex actions and settings workers to inform strategies that reduce discrimination and violence, increase social inclusion and equitable access to social resources, and enhance service provision. WHW will evaluate the research project by assessing the number of recommendations Evaluation implemented. Any health promotion activities implemented by WHW as an outcome of the research will include an impact, process and outcome evaluation.

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Gender norms Gender norms are an important social determinant of sexual and reproductive health (WHO, 2010a). Unlike the biological characteristics and differences between women and men known as ‘sex’, gender norms refer to the social and culturally constructed roles, behaviours and attributes associated with masculinity and femininity. Socially constructed gender norms have a powerful influence on people’s sexual identity, practices and behaviour and the way in which they enact their sexuality. Many women, particularly young women, negotiate sexual encounters through social pressures and constraints that impact directly on their ability to make decisions about safe sexual practices (Rosenthal and Browning, 2005). Dominant notions of femininity impact on young women’s attempts to negotiate safe sex, as the social stigma attached to teenage girls who appear ‘too knowledgeable or too prepared to have sex’ (Rosenthal and Browning, 2005: 34) limits many young women’s ability to negotiate safe sexual practices. Similarly, research into adolescent heterosexual relationships found that young men who hold traditional attitudes about masculinity report having more sexual partners, negative attitudes towards safe sexual practices that translate into low condom use, and are less inclined to believe in male responsibility to prevent pregnancy (Pleck et al, 1993). WHW is strongly committed to health promotion action designed to enhance respectful, gender equitable and non-violent relationships between young women and men where the responsibility for safe sexual practices, along with other facets of sexual and reproductive health, is shared. Girls Talk Guys Talk Increase community education and capacity building efforts to improve women’s access to Objective the knowledge, skills and resources they need for healthy relationships and sexual choices. Girls Talk Guys Talk is a health promoting schools program that uses a whole-school Social and approach to prevent violence and discrimination, reduce the impact of alcohol and drug use, behavioural rates of sexually transmissible infections and unwanted pregnancy among young people. The determinants program increases the capacity of young people to challenge gender and cultural norms, improve health literacy and help-seeking behaviours. Girls Talk Guys Talk specifically works with year 9 students. However, because the program changes the school culture and ethos it has positive outcomes for young people aged 11 to Population target 18 years. The program also works with adults employed in education, health, community and group women’s services, and local government settings. A complementary target group is parents, carers and families of young people. The whole school approach aims to strengthen the school and community partnerships. Program partners include young people, schools, the Department of Education and Early Program partners Childhood Development, local government, women’s and community health, community organisations and the parents and families of young people. Girls Talk Guys Talk is modelled on the World Health Organisation’s whole of school Health promotion approach and the VicHealth participation for health framework. The Girls Talk Guys Talk actions and settings program is an intensive six-term whole-school healthy relationships and sexual health program that integrates a number of health promotion actions in a planned and coordinated way across a school’s curriculum, community and culture. The project undertakes process, impact and outcome evaluation using a range of techniques including focus groups, pre and post participation surveys, interviews and observation. Data Evaluation is analysed to review the effectiveness of the program to achieve and maintain curriculum, community and cultural change in participating schools.

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Western English Language School Human Relations Program Increase community education and capacity building efforts to improve women’s access to Objective the knowledge, skills and resources they need for healthy relationships and sexual choices. The Human Relations Program works with newly arrived refugee and migrant young people Social and to enhance their health literacy relating to sexuality, healthy sexual decision-making and behavioural gender equitable respectful relationships. This skill and knowledge development assists these determinants young people preparing to enter into mainstream schooling. The program targets newly arrived refugee and migrant young people aged between 14 and Population target 18 years who speak English as a second language. Students who participate in the program group come from a diversity of cultural, ethnic and religious backgrounds. Program partners WHW has a long established program partnership with Western Region Health Centre and Maribyrnong City Council’s Phoenix Youth Centre. This five-week community education program is delivered twice a year in the school setting, Health promotion and covers a range of topics including respectful relationships, race-based discrimination, actions and settings contraceptive use and pregnancy prevention. Evaluation WHW will evaluate the program using post-session questionnaires, through participant observation and feedback from teachers, facilitators and interpreters.

Public policy and the law Public policy and the role of the law is a key social determinant of women’s sexual and reproductive health (WHO, 2010a). There are a suite of federal and state strategies that respond to certain aspects of sexual and reproductive health. However, Victoria remains without a policy framework that integrates both sexual and reproductive health to provide an overarching, evidence-based approach for research, program and service development, implementation and evaluation. As a result, policy responses are limited to preventing unplanned pregnancy or sexually transmitted infections, along with educational or behavioural-change approaches that, alone, do not provide a sustainable solution to sexual health inequity (O’Rourke, 2008). The law plays an essential but inevitably controversial role in determining women’s sexual and reproductive health status (Magnusson, 2005). The law can play a fundamental role in upholding or denying sexual and reproductive rights. For example, the Federal Government in 2004 amended the Marriage Act 1961 to state explicitly that marriage means the union of a man and a woman to the exclusion of all others. The Victorian Gay and Lesbian Rights Lobby argue that such legislation must be amended, as the right to marry the partner of one’s choice is a ‘key marker of adulthood and citizenship, social participation and belonging to family and community’ (VGLRL, 2010). In contrast, the Abortion Law Reform Act 2008 positioned abortion as a health concern and granted Victorian women the legal right to control their fertility, which is paramount in advancing women’s sexual and reproductive rights to freedom and autonomy. A key component of WHW work through Action for Equity is to influence and inform legislative reform that promotes equity, social inclusion and upholds and protects sexual and reproductive health rights.

Cultural norms Cultural norms, which refer to the beliefs, behaviours, customs, traditions and language of a society or community, is a key social determinant of women’s sexual and reproductive health (WHO, 2010a). For instance, cultural norms and assumptions often deem women with a disability to be asexual or characterise their sexual behaviour as inappropriate or immoral (Temple-Smith and Gifford, 2005). Women with disabilities’ right to reproductive freedom is ‘denied in a myriad of other ways, including … systematic denial of appropriate reproductive health care and sexual health screening, limited contraceptive choices, a focus on menstrual control, denial of access to assisted reproductive technologies, and, poorly managed pregnancy, birth and post natal care’ (Frohmader, 2002). Women’s Health West – Integrated Health Promotion Plan 2013 -2017

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Cultural practices, including female genital mutilation/cutting (FGM/C) are deeply symbolic for many women and their communities. FGM/C is known to cause long-term sexual and reproductive health complications for women as well as having physical and psychological health implications. In many communities, FGM/C is motivated by cultural beliefs about what is considered proper sexual behaviour, linking procedures to premarital virginity and marital fidelity (WHO, 2013). The practice is believed to reduce women’s libido and is associated with cultural ideals of femininity, modesty and hygiene (WHO, 2013). Family and Reproductive Rights Education Program (FARREP) Work with communities and mainstream specialist services in Melbourne’s west to prevent Objective FGM/C. FARREP’s ultimate goal is to prevent the occurrence of female genital mutilation/cutting (FGM/C). The program works at a systems level to influence, advise and facilitate culturally Social and inclusive and clinically appropriate service provision for women and girls affected by FGM/C. behavioural It also delivers direct work with community women designed to enhance their health literacy determinants and confidence, independence and leadership skills to make informed sexual and reproductive health decisions. The FARREP portfolio at WHW has six discrete projects. Target activities include community education with women who have migrated from FGM/C affected communities with a focus on Population target high prevalence practicing communities. WHW also delivers a young African women’s group FARREP program and partner with Western Region Health Centre to undertake work with men. Partners include women from communities known to practice FGM/C, settlement services, Program partners local government maternal and child health program, community health, general hospitals and statewide services. The FARREP program works in various settings including community health, hospitals, Health promotion educational institutions, and within the community. Sector and workforce development, actions and settings community education and capacity building efforts that engage a participatory approach and enhancing culturally appropriate service and program delivery. The FARREP program uses various qualitative and quantitative methods of evaluation, Evaluation including semi-structured interviews, focus groups, participant observation, and pre and post evaluation questionnaires for service providers.

Access to affordable, responsive and appropriate health services Women’s ability to access affordable, responsive and appropriate health services is a key determinant of sexual and reproductive health (WHO, 2010a). Women have a higher health service usage than men throughout the reproductive years, mainly due to contraceptive and reproductive health concerns (Temple-Smith and Gifford, 2005). Accessibility is closely linked to health providers’ attitudes and practices, as practitioners play a central role in the quality of, and women’s access to, sexual and reproductive health services (WHO, 2010a). Health services can be inaccessible to many women because of socio-economic status, dominant cultural norms, institutionalised racism, language barriers or culturally inappropriate services or support. Research has shown that migrant and refugee women are ‘significantly more likely to report being treated with disrespect… in the patient-provider relationship’ (Blanchard and Lurie, 2004). Similarly, national research has found that many lesbian, bisexual and transgendered women avoid disclosure of their sexuality or gender identity to health providers because of fear of discrimination, and are subsequently under-screened for various sexual and reproductive health problems as well presenting later for treatment after diagnosis (Pitts, 2005). Lack of culturallysensitive and appropriate clinical services, health promotion programs, trust between client and the clinician, and cost of services are also major barriers to supporting the optimal sexual and reproductive health of Indigenous women and their communities (VACCHO, 2009). Working to Women’s Health West – Integrated Health Promotion Plan 2013 -2017

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improve access to culturally appropriate services and health promotion projects for women from diverse backgrounds will be a key focus of WHW’s activities over the coming four years. Health and wellbeing workshops for women in prison Increase community education and capacity building efforts to improve women’s access to Objective the knowledge, skills and resources they need for healthy relationships and sexual choices. Women in prison are more likely to have been unemployed prior to incarceration, have lower Social and levels of education, and experience systematic and systemic discrimination and exclusion. behavioural Women in prison are far more likely than the general population to have experienced past determinants sexual assault, to have been paid for sex, and to have had a sexually transmissible infection. Population target The program will be delivered to approximately 12 women annually who are incarcerated at group Dame Phyllis Frost. WHW is delivering this program in partnership with Hepatitis Victoria and Western Region Program partners Health Centre’s Health Works, and is overseen by the Departments of Justice, Health and Corrections Victoria. The program, which will occur within the prison setting bi-annually, will provide holistic health Health promotion and wellbeing workshops for women to better support sexual and reproductive health and actions and settings wellbeing, and to prepare them for life post-release. WHW will evaluate the program through pre- and post- participant focus groups that assess Evaluation knowledge and skills development; 12 month follow up interviews will be conducted with women who participated to measure program outcomes.

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State priority: Promoting mental health Priority area: Promoting women’s mental health and wellbeing Mental ill health is a significant public health concern and is estimated to cost Victoria $5.4 billion a year (The Boston Report, 2006). It is now widely recognised that mental health and illness result from a complex interplay of biological, psychological, cultural, social, environmental and economic determinants of health (VicHealth, 2008). Individual factors and experiences, social interaction, societal structures, resource distribution and cultural values affect the mental health of individuals and the community as a whole (Busfield, 1996; Read, 2004; WHO, 2004). Poor mental health is associated with rapid social change, stressful work conditions, sex and gender discrimination, social exclusion, physical ill health, unhealthy lifestyles, and violence and human rights violations (WHO, 2010b). Many of the negative experiences and exposures to risk factors that impact on, and maintain mental ill health that disproportionately affect women, involve serious violations of their human rights (Bustow, 2003; WHO, 2004; WHO, 2008). Gender determines the differential power and control men and women have over the socioeconomic determinants of their mental health (WHO, 2008). This includes their social position, role, status and treatment in society, their exposure to specific mental health risks, and differences in mental health outcomes (WHO, 2008). Gender also interacts with other determinants including occupation, race, culture, ability, legal and political status, family composition, education, social and community support, access to health services, and a range of behavioural determinants (WHO, 2000; VicHealth, 2005). Victorian women are over represented in the prevalence of mental illness requiring a gendered analysis for prevention, early intervention and treatment.

Definitions WHW’s programs that are designed to promote women’s mental health and wellbeing are informed by the following internationally and nationally recognised definitions. The World Health Organisation defines mental health as: a state of wellbeing in which an individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community (WHO, 2010c: 1). VicHealth’s definition of mental health and wellbeing includes the: embodiment of social, emotional and spiritual wellbeing. It provides individuals with the vitality necessary for active living, to achieve goals and to interact with one another in ways that are respectful and just (VicHealth, 2005: 1). Mental health promotion requires action to ensure positive environments for good health and wellbeing that: influence determinants of mental health and redress inequalities through the implementation of effective multi-level interventions across a broad number of sectors, policies, programs, setting and environments (Keleher and Armstrong, 2006: 13).

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Evidence supporting promoting mental health and wellbeing as a WHW priority Poor mental health and associated disorders are common and will affect more than 25 per cent of people at some time during their life (WHO, 2010). The burden of mental illness is growing and it is expected that by 2030 depression will be a leading cause of disease worldwide (WHO, 2001). Evidence for why action is needed to promote mental health and wellbeing include:







Depression and anxiety will be the greatest single contributor to the burden of disease in Australian women and the third greatest in Australian men by 2023 (Australian Institute of Health and Welfare, 2007) Up to 90 per cent of eating disorders occur in women (Australian Bureau of Statistics, 2008) One in six recent mothers experience a mild, moderate or severe form of peri-natal and/or postnatal depression (Australian Women’s Health Network, 2012) About one in five Victorians will experience a mental illness – with anxiety and depression the most prevalent disorders (Department of Health, 2011c) Mental illness is the largest single contributor to the disability burden in Victoria, accounting for 70 per cent of the disease burden in young people (The Boston Report, 2006) Carers experience higher rates of depression and two thirds of carers are female (Deakin University, 2007; Australian Bureau of Statistics, 2009)

Mental health and wellbeing frameworks The World Health Organisation states that action that respects and protects civil, political, socioeconomic and cultural rights is central to mental health promotion, as without the freedom and security provided by these rights it is difficult to maintain mental health and wellbeing (WHO, 2010c). The World Health Organisation (2010) insists that a range of inter-sectoral strategies and interventions are needed to promote mental health. These include socio-economic opportunities for women, violence prevention programs, policies that achieve secure housing, and community development programs that support disadvantaged population groups including Indigenous, refugee and migrant communities. The Melbourne Charter for Promoting Mental Health and Preventing Mental and Behavioural Disorders (2013) is the outcome of the Global Consortium for the Advancement of Promotion and Prevention in Mental Health (GCAPP) conference. The charter provides a framework for action in mental health promotion. It is underpinned by the belief that mental health and wellbeing is best achieved through equitable, just and non-violent societies and advanced through respectful, participatory means where culture, cultural heritage and diversity are valued (VicHealth, 2013). Women’s Health West’s programs that promote women’s mental health and wellbeing are informed by the VicHealth (2005) Mental Health Promotion Framework 2005-2007, which has provided an evidence-based conceptual framework for health promotion practice. More recently the VicHealth Participation for Health: Framework for action 2009-2013 has strongly informed WHW’s health promotion work. WHW also uses the Evidence-based Mental Health Promotion Resource (2006), which presents an overview of both national and international evidence to advance policy, research and practice responses to the promotion of mental health across Victoria. The report is informed by a determinants approach and makes the case for three overarching social and economic determinants of mental health – social inclusion, freedom from ethnic and race-based violence

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and discrimination, and access to economic resources and participation (Keleher and Armstrong, 2006).

Social determinants of women’s mental health and wellbeing Social inclusion Social inclusion – including supportive relationships, involvement in one’s community and group activities, and civic engagement – is an important social determinant of women’s mental health and wellbeing (VicHealth, 2007). While social inclusion is a theoretical, widely contested concept, it is commonly conceptualised as a multi-dimensional process that enables participation in economic, social, political and civic domains (Silver, 2010). Social inclusion is not the antonym of social exclusion, however the two concepts are inextricably intertwined (Keleher and Armstrong, 2006; Silver, 2010). Social exclusion occurs at a societal and individual level, across various domains and throughout the life course and is the process of being shut out of social, economic, political and cultural systems and being denied freedom, dignity and respect (Smyth, 2010; VicHealth, 2007). Despite making up 45 per cent of the Australian workforce, women are still significantly underrepresented in senior leadership and management positions across all public and private domains. Data from the Australian Bureau of Statistics (2012a) shows that seven out of ten federal and state parliamentarians are men and that the representation of women in state and federal parliament had only slightly increased over the last ten years, with a significant recent decline federally. In 2012, 7 of the 202 chief executive officers of the top 200 ASX companies were women (ABS, 2012a). This statistic has remained below 5 per cent for the past decade (ABS, 2012a). Women from diverse ethnic, religious and cultural backgrounds experience high rates of exclusion from leadership and decision-making positions (Australian Human Rights Commission, 2010). Increasing opportunities for women, particularly young women, to become community leaders is therefore an important health promotion activity for WHW. Lead on Again To provide strength based training to increase the leadership skills, knowledge and capacity Objective of young women from diverse backgrounds and to facilitate their participation in community and leadership activities. Lead on Again is a leadership initiative that aims to increase young women’s civic Social and participation, social inclusion and control over the decisions affecting their lives. The program behavioural enables young women to feel safe and connected, recognise their strengths, develop new determinants skills and become active participants in our community. Population target The program is delivered annually to approximately 15 young women from culturally and group linguistically diverse backgrounds aged between 16 and 24 years. WHW partners with the Western Young People’s Independent Network to deliver Lead on Program partners Again. Local practitioners also deliver sessions to increase young women’s knowledge of accessible services in their region. The program consists of a week of intensive workshops and then supports participants to Health promotion deliver their own event and engage in leadership, civic engagement and other community actions and settings opportunities. Beyond this program phase, young women are provided with mentor support to take up leadership initiatives through the Western Young People’s Independent Network. WHW evaluates Lead on Again using qualitative and quantitative data collected via Evaluation participant and facilitator focus groups and a questionnaire implemented pre- and postprogram delivery. In the north-west metropolitan region, less than half of women reported participating in citizen engagement activities over the last 12 months (CIV, 2012). WHW values women’s right to, and Women’s Health West – Integrated Health Promotion Plan 2013 -2017

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realisation of, participation as integral to equity and justice for women in the west (WHW, 2012). Women’s involvement in their community, group activities and civic engagement is instrumental to social inclusion and positive mental health and wellbeing (VicHealth, 2008). Women’s capacity to exercise their rights in order to influence positive social change through civic participation is a cornerstone of Australian democracy. The Victorian Human Rights and Equal Opportunity Commission (2010) maintains that Victorian women need greater access to relevant, appropriate and useful education and training about human rights. WHW’s Our Community, Our Rights program delivers human rights training and support to strengthen the capacity of women in the west of Melbourne to participate in civil society and to facilitate change on human rights issues of importance to their community. Our Community Our Rights Develop women’s understanding, skills and confidence to engage in actions that promote and Objective protect their rights, and to actively participate in their communities and civil society. Research shows that newly-arrived women from refugee and migrant backgrounds are less likely Social and to invoke human rights protections or organise together for societal change, despite experiencing behavioural serious human rights violations in Australia, their home country or en route to Australia. Our determinants Community Our Rights aims to increase women’s capacity to effectively respond to and reduce human rights violations experienced by their communities. Population target This yearly program engages 12 women from refugee and migrant backgrounds from newlygroup arrived communities. Our Community Our Rights is overseen by an expert advisory group comprised of Program partners representatives from the Victorian Equal Opportunity and Human Rights Commission, migrant and refugee services, the health sector and other organisations undertaking similar work, and community leaders. WHW conducts extensive community consultation to understand women’s needs and Health promotion aspirations, and then delivers a series of human rights education workshops designed to actions and increase participants’ capacity to invoke human rights, participate in civil society and facilitate settings change. Following workshop delivery, WHW provides structured and intensive support for participants to design and implement their own human rights-based projects responding to community needs. The project is externally evaluated at baseline, mid-term and end-term stages utilising the Most Significant Change technique. Data gathered via participant interviews, focus groups and Evaluation questionnaires is analysed to understand changes in participants’ knowledge, skills, confidence and community participation. This evaluation data will also inform necessary changes to the program model to ensure it meets its goal and objective. Being actively involved in local organisations is an important form of civic engagement for many women that also enables them to develop the confidence and skills they need to increase their participation in other domains (Victorian Human Rights and Equal Opportunity Commission, 2010). WHW will develop and implement a whole-of-organisation client and community participation strategy to respond to this need. The strategy will support community women to shape WHW’s services, programs and organisation ‘through viable and genuine decision-making and/or the ability to influence outcomes that are deemed meaningful to women, by women themselves’ (WHW, 2012).

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Client and Community Participation Strategy Develop women’s understanding, skills and confidence to engage in actions that promote and Objective protect their rights, and to actively participate in their communities and civil society. Social and The Client and Community Participation Strategy recognises and takes action on the important behavioural connection between the participation of women in political, social, economic and cultural life determinants and their overall health and wellbeing. Women who work, live or play in Melbourne’s west, including those who are currently or have Population target previously used WHW services. Specific measures will be implemented to ensure that the group strategy is inclusive of young women, women with a disability, LGBTIQ communities, women from refugee and migrant backgrounds, and Aboriginal and Torres Strait Islander women. The Client and Community Participation Strategy is driven by an internal working group with representation from across our organisation. We will consult and partner with communities in Program partners the western region. WHW is also a member of the Western Region Community Engagement Network, which has representation from local government and the community and health sector. The Client and Community Participation Strategy is an organisation-wide initiative that aims to Health promotion increase clients and community women’s participation in services, programs and our actions and settings organisation as a whole. The strategy has five objectives that will drive sustainable action across all organisational departments. WHW has developed an audit tool to document where and how participation is already Evaluation occurring. We have conducted an initial audit to gather baseline data and this process will be repeated after new strategies have been implemented. While many groups of women experience social exclusion and subsequent poor mental health, women with a disability experience significantly high rates of exclusion, marginalisation and discrimination and as such are a key target population for WHW’s health promotion program. Negative stereotypes associated with gender and disability further compound the exclusion of women with disabilities from support services, social and economic opportunities and participation in civic and community life (WWDA, 2011). Women with a disability have higher rates of poverty, housing insecurity and stress, lower levels of education and employment, when compared with men with a disability and women who do not have a disability (VicHealth, 2012b). Almost half of Australian women with a disability are shut out of employment; with only 49 per cent participating in the workforce compared with 60 per cent of their male counterparts (ABS, 2012b). High rates of gender-based violence also compound the social exclusion and poor mental health outcomes of women with a disability. Statistics indicate that 90 per cent of women with an intellectual disability have been sexually assaulted (Frohmader, 2002), while a Victorian study of women with a disability living in licensed boarding houses reported that violence is a daily lived experience (Attard and Price-Kelly, 2010).

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Sunrise Objective Social and behavioural determinants Population target group Program partners Health promotion actions and settings

Evaluation

Enable women with a disability to access tools, resources and appropriate services, be socially connected and optimise their mental health and wellbeing. Sunrise women’s groups enable women to increase their social connectedness and improve their engagement with services, education and employment opportunities, and the wider community. Isolated women 18 years and over experiencing a disability (including intellectual, physical or mental illness) living in Melbourne’s west. Project partners include local governments in the west, disability and mental health services, and organisations that work primarily with minority populations (e.g. Aboriginal women and GLBTI communities). Sunrise provides safe, inclusive, and supportive social group activities for women with a disability to improve their health and wellbeing in an environment that is welcoming and is responsive to their individual needs. Sunrise groups are located in western metropolitan LGAs, with priority given to areas within the outer west growth corridors, and those areas where communities experience higher levels of disadvantage. WHW will collate annual quantitative and qualitative data relating to participants’ health and wellbeing improvement and barriers to optimal health. Feedback will also incorporate participant’s satisfaction with the program as well as areas they would like to see improved.

Power On Objective Social and behavioural determinants Population target group Program partners Health promotion actions and settings

Evaluation

Provide women with a disability with the tools and resources required to access appropriate services, enhance their social connections and optimise their mental health and wellbeing. Power On assists women to recognise external factors that lead to poor self esteem and its effect on their capacity to take control over their wellbeing. Within this context, women are assisted to identify individual strengths and become increasingly proactive in attaining positive lifestyle outcomes. Women experiencing mental illness and women in unpaid caring roles for family members experiencing mental illness. Power On has been delivered in Victoria, Queensland and Tasmania by trained staff who work in mental health services. WHW aims to develop Power On into a train-the-trainer program to extend its reach to services across Victoria. Power On is a 12-session program that is run in mental health and carer support service settings. The workshops are peer facilitated and topics are designed to enhance women’s capacity to take control over and improve their wellbeing by building on existing and new strengths and skills. An independent external evaluator has collected qualitative data relating to program outcomes. This evaluation process included extensive consultations with women who participated in workshops and with mental health staff who have been involved in the delivery of Power On. WHW will assess the train-the-trainer model using impact and process evaluation.

Ethnic and race-based discrimination VicHealth (2008) identifies ethnic and race-based discrimination as a social determinant of mental health and wellbeing. Ethnic and race-based discrimination refer to processes of ‘discrimination founded upon ethnicity, perceived “racial” distinctions, culture, religion or language’ (VicHealth, 2008). It represents a pattern of unfair treatment that is justified by social norms and beliefs designed to maintain privileges for one group at the deprivation of others (VicHealth, 2008). A strong body of research shows an established link between self-reported ethnic and race-based discrimination and depression, psychological distress, stress and anxiety (Paradies, 2006). Being a victim of ethnic and race-based discrimination is associated with chronic disease, such as diabetes, smoking, substance misuse and poor general health outcomes (Larson et al, 2007; Paradies, 2006).

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Racism and racist intimidation have emerged as prominent contributors to inhibiting the successful settlement of migrants, refugees and asylum seekers, particularly for women (Rees and Pease, 2006). Between October 2010 and October 2012 there were 8,513 female migration arrivals in Melbourne’s west, of which 665 were humanitarian entrants mainly from Burma (Rich, 2013). Refugee and asylum seeker women experience depression, anxiety and other mental health difficulties within the context of pre-migration, migration, and resettlement for a range of reasons that interact in a complex manner. These include human rights violations such as torture, discrimination, and lack of access to employment, housing and health services (Kordes, 2006; Rees and Pease, 2006). Aboriginal and Torres Strait Islander communities continue to experience high rates of racism, with a study revealing that 43 per cent of Indigenous respondents report daily discrimination (Dunn et al, 2005). Indigenous women’s poor mental health status is impacted by factors such as colonisation,1 high rates of unemployment, sole parenting, pressure associated with multifamily households, and an overrepresentation in incarceration and the child protection system with high child removal rates (Swan and Raphael, 1995; DHS, 2006). High rates of violence are also known to significantly impact on Indigenous women’s poor mental health status (Swan and Raphael, 1995; DHS, 2006). Regardless of ethnic background, people born in countries where the main language spoken is not English are more likely to experience discrimination in employment, education, housing and policing (VicHealth, 2008). This is often compounded for women from ethnic-minorities who experience race-based and sex discrimination. Research in Australia and overseas documented a surge of racism against Muslim communities after the September 11 terrorist attacks in 2001 (AMWCHR, 2008). A study by the Australian Muslim Women’s Centre for Human Rights (2008) found that Muslim women’s reported experiences of racism escalated post 9/11, which impacted on their sense of safety, particularly in public places, and eroded their social participation and sense of belonging in Australian society. The research also found that Muslim women who wore the hijab and African Muslim women reported experiencing higher levels of racism than other Muslim women (AMWCHR, 2008). Prevention of ethnic and race-based discrimination Explore the impact of race-based discrimination on women in the western region and develop Objective strategies and resources to assist organisations and communities to prevent it. Many women in Melbourne’s west report pervasive and systemic ethnic and race-based Social and discrimination that has a debilitating impact on their health and wellbeing. WHW will undertake behavioural an action research project that explores women’s experiences of racism and identifies determinants strategies to prevent it. Population target Women from diverse ethnic, cultural and religious backgrounds who reside in Melbourne’s group west, as well as service providers who work with diverse communities. An expert advisory group consisting of community women from migrant and refugee Program partners backgrounds and relevant service providers will be established to oversee the research project and the subsequent development of primary prevention tools and resources. WHW will conduct a series of interviews and workshops with community women who have experienced ethnic and race-based discrimination, and local service providers. The project will explore safe ways to discuss and define racism, how it affects women living and working in Health promotion Melbourne’s west and strategies to prevent discrimination. It will explore women’s experiences actions and settings of racism in settings including the workplace, transport and educational institutions, among others. WHW will produce a research paper and subsequent primary prevention tools or resources designed to promote a culturally diverse and inclusive community informed by 1

The historical destruction and genocide of Indigenous communities through practices, policies and laws that resulted in the forcible removal of Indigenous children from their mothers and kinship continues to have a detrimental impact on Indigenous people’s mental health and wellbeing (Swan and Raphael, 1995).

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evidence-based practice and the findings of this research project. The evaluation framework for the research project will include an assessment of the number of Evaluation recommendations actioned as consequence of this work. WHW will also measure the distribution and influence of the anti-racism tools and resources.

Access to economic resources and participation International evidence demonstrates that socio-economic disadvantage is a risk factor for poor mental health outcomes, with the strongest association being indicators of poverty, including lower levels of education (WHO, 2010). Sustained economic disadvantage and low income produces the greatest risk of mental and physical ill health (VicHealth, 2007). VicHealth (2008) identifies access to economic resources as a social determinant of mental health and wellbeing, as access to appropriate employment, education, housing and financial resources protect and promote mental health and wellbeing (Keleher and Armstrong, 2006). When compared to men, Australian women experience disadvantage on nearly every economic indicator (Cunningham and Zayes, 2000; Read, 2004; Black, 2007). The persistent gender wage gap has a profound impact on women’s financial security. Across the west, women report a lower weekly gross income than their male counterparts, which impacts on their economic independence and financial security (WHW, 2013). The 2011 Census data showed that 21.3 per cent of women in the west reported a weekly income of less than $300 (compared to 14.7 per cent of men) and more than one in ten women (12.3 per cent) reported having nil or negative individual income (compared to 8.4 per cent of men). Women, particularly women from culturally and linguistically diverse backgrounds, are overrepresented in non-career part time or casual employment, which provides limited opportunities for training, development and career progression (Department of Commerce, 2012). The most common industries of employment for women in the west are healthcare and social assistance (16.6 per cent), retail (12.4 per cent) and education and training (10.7 per cent); all traditionally undervalued and poorly paid industries (WHW, 2013; Department of Commerce, 2012). Unemployment rates are also high for women in the west, with one-third of women reporting that they were not in paid employment (WHW, 2013). In 2011 Census data showed that 179,510 women in Melbourne’s west speak a language other than English (WHW, 2013). Of these women, almost one in five (17.8 per cent) reported speaking English not well or not at all compared to 13.2 per cent of men (WHW, 2013). Low English language proficiency significantly reduces women’s ability to engage in education and employment opportunities, which increases their vulnerability to poor mental health outcomes, given the strong correlation between mental ill health and low socio-economic status (Read, 2004; Black, 2007). In Australia, women head 83 per cent of sole parent families. In the western region 27.1 per cent of one-parent families, the overwhelmingly majority single mothers, reported that their weekly household income was less than $600 (WHW, 2013). Women who do not have the economic resources to care for themselves and their families experience higher levels of anxiety, depression and substance abuse, which have a cumulative effect on long-term mental health outcomes for them and their children (VWHN, 2012).

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Financial Literacy Program Increase the capacity of women from newly arrived communities in the west to negotiate Objective financial systems, take control of financial decision-making and access economic resources by providing financial literacy program to target communities. Women from newly arrived communities face cultural and language barriers that impede their Social and ability to engage effectively with Australian financial systems. This major settlement challenge behavioural compounds women’s economic disadvantage. The Financial Literacy Program aims to determinants increase participants’ access to economic resources, improve women’s capacity to negotiate financial systems and have control over their financial decision-making. Population target The program is delivered to approximately 15 to 20 women from newly arrived communities group twice per year. WHW delivers the program in partnership with settlement, financial counselling and ethnoProgram partners specific community organisations. By incorporating presentations from local services, community women build relationships with relevant service providers in their area that can provide ongoing support. WHW undertakes extensive community consultations to understand the needs of each Health promotion community, and then delivers a series of uniquely tailored workshops designed to build actions and settings participants’ financial capability. Evaluation WHW will evaluate the program through a series of participant focus groups that assess knowledge and skills development. Poor access to economic resources also increases women’s risk of chronic disease, as low socioeconomic status is an established social determinant of diabetes (Department of Health, 2011c). Diabetes is a chronic condition marked by high levels of glucose in the blood and is Australia’s fastest growing chronic disease (National Diabetes Service Scheme, 2013). There are three types of diabetes that affect women – type one, type two and gestational diabetes occurring during pregnancy. At a population level, the prevalence of diabetes is higher among men than in women (National Diabetes Service Scheme, 2013). Sex-disaggregated data from the National Diabetes Service Scheme (2013) shows that female residents in Brimbank and Hobsons Bay have higher rates of diabetes that the national average. Women in Maribyrnong have a higher diabetes incidence than their male counterparts, which is uncommon. All three of these LGAs have high rates of socioeconomic disadvantage. Brimbank

Hobsons Bay

Maribyrnong

Melbourne

Melton

Moonee Valley

Wyndham

National

Female

6.5 % High

5.8 % Moderate

4.7 % Moderate

2.1 % Very low

4.9 % Moderate

4.6 % Moderate

4.7 % Moderate

5.4 %

Male

6.8 % High

5.9 % Moderate

4.6 % Low

2.5 % Very low

5.7 % Moderate

5.0 % Moderate

5.0 % Moderate

5.8 %

Source: The National Diabetes Services Scheme (2013) The prevalence of type two diabetes is growing in Victoria, which is largely attributed to health inequities (Department of Health, 2011c). Women from the lowest income bracket are twice as likely to report having been diagnosed with diabetes than women in the highest income bracket (WHV, 2010). Aboriginal women are also at high risk, as unlike their Anglo-Australian counterparts, Indigenous women have a higher reported incidence of diabetes than men (WHV, 2010). Migrant and refugee women, in particular, women from the Pacific Islands, India, China, the Middle East and North African backgrounds are also at high risk of developing diabetes (WHV, 2010). So too are women with a disability, older women and women who experience obesity. The age of diabetes onset is decreasing in women due to increasing rates of obesity in younger women (WHV, 2010). Women’s Health West – Integrated Health Promotion Plan 2013 -2017

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Research demonstrates that type two diabetes can be prevented or delayed by lifestyle interventions that focus on reducing risk factors such as tobacco smoking, physical inactivity and obesity, and excessive alcohol consumption. Yet, rarely do health promotion interventions redress the social determinants that contribute to diabetes, including gender. There will subsequently be a focus on WHW health promotion activities designed to prevent type two diabetes among women from diverse and disadvantaged backgrounds. Gender, diabetes and equity project Undertake a gendered analysis of chronic disease in our region, beginning with diabetes, and Objective examine the contribution of social determinants to these diseases in order to support understanding of good practice with women at risk and experiencing chronic disease. Social and The Gender, diabetes and equity project will explore the social determinants that drive high behavioural rates of diabetes in Melbourne’s west. In particular, the project will focus on the prevalence determinants and nature of diabetes among women who experience socio-economic marginalisation. Women who work, live or play in Melbourne’s west and experience or are at risk of Population target experiencing diabetes. Specific measures will be implemented to highlight the unique group experiences of women from refugee and migrant backgrounds, women with a disability, women who experience mental illness, and Aboriginal and Torres Strait Islander women. Project partners include community health agencies, local government, primary care Program partners partnerships, medicare locals and Women’s Health Victoria. We will also explore partnership opportunities with research bodies working in this field. The Gender, diabetes and equity project will review current evidence and connect with health agencies and research bodies to identify instances where research could be strengthened by highlighting the different experiences of women when compared to men. WHW will support Health promotion regional partner organisations to embed sex-disaggregated data and gender sensitive actions and research in their work to redress the high rates of diabetes in Melbourne’s west. This work will settings also collaborate with and support Women’s Health Victoria to meet their statewide responsibility of providing expert advice on the health and wellbeing of women across different regions. WHW will use an audit tool to evaluate where organisations working to prevent or respond to Evaluation diabetes are using sex-disaggregated data and gender sensitive research to inform their practice approach.

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State priority: Promoting mental health Priority area: Prevention of violence against women Violence against women is prevalent, serious and preventable (VicHealth, 2007). It takes many forms and occurs within all communities, irrespective of socio-economic status, ethnicity, religion, sexuality or ability. Intimate partner and family violence is a gendered phenomenon. Women constitute the overwhelming majority of victims/survivors of violence that − for the most part − is perpetrated by men they know (Mouzos and Makkai, 2004; WHO, 2013). For Victorian women aged between 15 and 44 years, intimate partner violence is the leading cause of preventable death, disability and illness (VicHealth, 2007). Men’s violence against women is a greater contributor to the burden of disease than factors such as tobacco use, alcohol-related harm and physical inactivity (VicHealth, 2007). Violence against women is therefore a significant public health concern that costs the Victorian community in excess of $3.4 billion a year. This is forecast to increase to $3.9 billion in 2021 if concerted action is not taken. Preventing violence before it occurs has a significant impact on the social, economic and health consequences for women, their children and our broader community. Investing in primary prevention efforts is fundamental to ensuring that women and children’s right to live free from violence and discrimination is protected and upheld (Victorian Human Rights Charter, 2006).

Definitions WHW’s violence prevention programs are informed by the United Nation’s Declaration on the Elimination of Violence against Women as: any act of gender-based violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life (UN, 1993). As articulated by the World Health Organisation, violence against women encompasses: physical, sexual and psychological violence occurring in the family and in the general community, including battering, sexual abuse of children, dowry-related violence, rape, female genital mutilation2 and other traditional practices harmful to women, non-spousal violence and violence related to exploitation, sexual harassment and intimidation at work, in educational institutions and elsewhere, trafficking in women, forced prostitution, and violence perpetrated or condoned by the state (WHO, 1996).

Evidence supporting prevention of violence against women as a WHW priority There is a significant body of international, national and Victorian research on the incidence of violence against women. Because violence against women often goes unreported, the true extent 2

WHW recognise that female genital mutilation is a gender-based human rights violation and a form of violence against women. However, in line with best practice, WHW works to prevent the practice within a sexual and reproductive health promotion framework.

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of the problem remains unknown. However, the reported incidence in Australia is evidence alone that primary prevention action is urgently needed.





One in three women experience intimate partner violence in their lifetime (ABS, 2006) One in five women, compared to one in twenty men, experience sexual harassment in the workplace (Broderick et al, 2010) One in ten women is raped by their partner (Parkinson, 2008) Women are five times more likely to be murdered than their male counterparts. On average, a woman is killed every week by her male partner or ex-partner, often postseparation (Dearden and Jones, 2008)

According to Victoria Police’s reported crime data, women in Melbourne’s west are particularly at risk of violence. During 2011-2012, in the north-west metropolitan region there were:



15,534 reported family violence incidents, which accounted for 30.8 per cent of reported incidents in Victoria (WHW, 2013) The highest rates of reported family violence were in the municipalities of Melton (1,166.1 per 100,000) Brimbank (972.3 per 100,000) and Wyndham (925.1 per 100,000), all of which were higher than the Victorian state average of 910.3 per 100,000.

In 2012-2013 WHW experienced a 35 per cent increase in family violence referrals, up from an increase of 26 per cent the previous year. Actions to prevent violence against women are urgently required to avoid the costs of family violence to the community.

Primary prevention of violence against women framework Primary prevention strategies seek to prevent violence against women before it occurs (VicHealth, 2007). Despite considerable practice knowledge, violence prevention is an emerging area of public health and only a small number of interventions have been rigorously evaluated (WHO, 2009). Nonetheless, there is ‘broad international consensus that the prospects for primary prevention are sound’ (VicHealth, 2007: 12). WHW’s primary prevention programs are in line with VicHealth’s frameworks as they work to redress the underlying social determinants of violence against women through a range of mutually reinforcing interventions. Because a range of social factors cause and contribute to violence against women, WHW’s work includes action across diverse settings such as workplaces, the community and health sector, local government and educational institutions. Our work targets the multiple levels of influence – societal, organisational, community, as well as supporting individuals to develop knowledge and skills for gender-equitable respectful relationships.

Social determinants of violence against women A strong body of literature has identified adherence to rigidly defined gender roles and the unequal distribution of power and resources between men and women as the underlying social drivers in the perpetration of violence against women (VicHealth, 2007; WHO, 2009; Fergus, 2012). VicHealth’s (2007) review of the international evidence about the factors that cause violence against women found two consistent themes in the expert literature. These were:



the way gender roles, identities and relationships are constructed and defined within societies, communities and organisations and by individual women and men; and the distribution of power and material resources between men and women (VicHealth, 2007: 34).

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However, there are minor differences in the specific factors identified in VicHealth’s ecological approach to understanding violence proposed by various experts. While there is strong consensus that the underlying social determinants of violence against women are associated with gender inequity and gender role socialisation, the literature varies about whether broader cultures of violence are a contributing factor or a stand-alone determinant of violence against women (VicHealth, 2007). 3 As such, further research that explores broader cultures of violence as a determinant of violence against women is needed to inform effective primary prevention practice. When undertaking primary prevention efforts, it is also important to note that a number of factors can contribute to, as opposed to cause, violence against women. These include alcohol abuse, illicit drug use, childhood exposure to violence, income, occupation and education status (Mouzos and Mikkai, 2004; Gil-Gonzales et al, 2006). Contributing factors are ‘neither necessary nor sufficient conditions for violence to occur…as these risk factors are not salient for many men who are violent’ (VicHealth, 2007: 28). For example, a meta-analysis undertaken by Diana GilGonzales and colleagues (2006) found a weak association between alcohol use and violence against women. While alcohol can exacerbate existing patterns of violence, it is not the cause of violence against women (VicHealth, 2007). VicHealth (2007) maintains that a number of risk factors become significant when they interact with broader social norms pertaining to rigid gender roles and stereotypes and inequitable power relations between men and women. The distinction between social determinants and contributing risk factors for violence against women has implications for the efficiency of primary prevention programs. Programs that respond to the contributing factors will result in sustainable, effective reductions in violence against women only when they redress the underlying determinants of gender inequity (VicHealth, 2007). Prevention strategies must ‘above all promote gender equality and empower women and girls, but a myriad of complex and intersecting factors at other levels also need to be taken into account’ (Fergus, 2012: 20).

Adherence to rigid gender roles and stereotypes The different gender roles, attributes and behaviours assigned to women and men are shaped and reinforced by our society, community, family and peers (WHO, 2009). Gender roles create inequities between women and men that mean women occupy a subordinate social status and limited formal access to power, resources and opportunities (WHO, 2009; VicHealth, 2007). While the relationship between gender and violence is complex, rigid gender roles and stereotypes are identified as one of the most important underlying social determinants of violence against women (VicHealth, 2007; WHO, 2009). Studies show that the prevalence of men’s violence towards women is higher in societies in which:




Masculinity and manhood is culturally defined in relation to dominance, toughness and male honour Gender roles are more rigidly defined There is a relatively high degree of gender segregation (VicHealth, 2007: 35; Flood and Pease 2006; Nayak et al, 2003).

In most cultures, men and boys are expected to behave in dominant and aggressive ways, which can lead to a social acceptance of violence (UN Women, 2013). For example, an international study of 17 countries found that a quarter of respondents thought that it was justifiable for a man

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to beat his wife (UN Women, 2013). Social and gender norms that shape and socialise the way in which men and boys should behave is a cause of violence against women (UN Women, 2013). Cross-cultural studies of intimate partner violence have also found that nearly a fifth of peasant and small-scale societies are free from gender-based violence (UNFPA, 2013). UNFPA insists that the existence of such cultures prove that men’s violence against women ‘is not the inevitable result of biology or sexuality, but more a matter of how society views masculinity’ (UNFPA, 2013: 2). People who hold traditional views about gender roles or who are less likely to support equality between women and men are more likely to condone, justify and excuse violence against women than those who hold more egalitarian values (Flood and Pease, 2006; VicHealth, 2009). A national survey of community attitudes found that men were more likely than women to adhere to rigid gender roles and hold violence-supportive attitudes (VicHealth, 2009). Men who hold a strong belief in male dominance are also more likely to perpetrate violence against an intimate partner than those who do not (Abrahams et al, 2006). A critical component of violence prevention interventions is to redress entrenched social expectations and gender stereotypes and in turn promote equitable social norms, identities and relations between women and men (WHO, 2009). Preventing Violence Together To embed and drive cultural change across local government and community health to Objective redress the determinants of violence against women. Preventing Violence Together: Western Region Action Plan to Prevent Violence Against Social and Women, facilitates a coordinated, action-based approach to the prevention of violence behavioural against women across the western region. The vision for Preventing Violence Together (PVT) determinants is communities, cultures and organisations in the western region that are non-violent, nondiscriminatory, gender equitable and promote respectful relationships. Preventing Violence Together consists of both ‘whole-of-population’ strategies, as well as Population target those tailored to meet the needs of particular groups, such as Indigenous and newly-arrived group refugee and migrant communities. The Preventing Violence Together partnership is comprised of 16 agencies including seven Program partners local governments, four community health services, two primary care partnerships, family violence and women’s health services, and the western regional Indigenous-specific family violence action group. The program includes a range of objectives and key strategies, including building capacity for Health promotion organisational change and workforce development, strengthening community leadership and actions and settings establishing effective partnerships for sustainable prevention. The funding provided by the Department of Justice for the United: Preventing Violence Against Women in the West project will further enable implementation of a range of prevention strategies by partner agencies. The Australian Research Centre in Sex, Health and Society is contracted to evaluate the Evaluation program, which involves all partner agencies, and explores the process, impact and outcome of the partnership in promoting gender equity and preventing violence against women in the west.

Unequal power relations between women and men Gender roles and stereotypes and unequal power relations between women and men are inextricably interlinked. Gender inequities are pervasive in all societies. Biases in power, resources, entitlements, norms and values, and the way in which communities, institutions and organisations are structured all have a negative impact on the health and wellbeing of women and girls (Marmot et al, 2008). Marmot et al insist that gender inequities influence health through women’s lack of decision-making power, unfair divisions of unpaid work and caring responsibilities, and ultimately through the prevalence of violence against women, which compromises women’s mental and physical health and wellbeing. Women’s Health West – Integrated Health Promotion Plan 2013 -2017

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Evidence shows that male dominance; control of wealth and economic decision-making power is an underlying social determinant of violence against women (WHO, 2009; VicHealth, 2007). There is a higher incidence of violence in cultures and contexts where men’s dominance has strong social support and where men control the family wealth (Heise, 1998). Research undertaken in the United States also demonstrates the causal links between unequal power relations and gender-based violence in interpersonal relationships (Heise, 1998). The study showed that women’s economic dependence on their husband is a predictor of severe physical and sexual violence (Heise, 1998; VicHealth, 2007). The interplay between power, gender inequity and violence also influences rates of violence against young women in dating relationships (Vezina and Herbert, 2007). Research has demonstrated the causal link between men’s power and privilege and violence, as when power relations between women and men are more equitable the prevalence of violence against women is lower (UNIFEM, 2010). As demonstrated in the UNIFEM (2010) graph below, when the leading global indices for gender equality are assessed, countries with greater equity between women and men tend to have lower levels of gender-based violence. These measures examine indicators such as life expectancy, sex ratio at birth, adult literacy, primary, secondary and tertiary education enrolment rates, participation in the formal labour force, estimated earned income, wage equality and numbers of seats in legislative, ministerial and senior political positions (UNIFEM, 2010).

Source: UNIFEM (2010) Gender inequity and discrimination against women and girls reinforce unequal power relations between women and men (UN Women, 2013). Women and girls subordinate social power in their relationships, communities and within society increases their risk of violence by men and boys who ‘enforce their power over women through physical, sexual, emotional and economic violence’ (UN Women, 2013: 39). Hence, if we are to prevent violence against women, primary prevention efforts must work to promote equal and respectful relationships between women and men at an individual, community and societal level, as well as the equitable distribution and access to power, resources and opportunities.

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You, Me and Us Objective

Social and behavioural determinants

Population target group Program partners

Health promotion actions and settings

Evaluation

Raise young people’s awareness of ethical behaviour and assist them to develop protective behaviours and the skills needed to conduct respectful relationships. You, Me and Us aims to redress the drivers of violence against women and increase the capacity of young people to conduct respectful, gender equitable relationships through a peer education model. The program builds young people’s knowledge and skills to identify behaviours associated with healthy and unhealthy relationships, identify attitudes that underpin and perpetuate gender inequity, understand their legal rights and responsibilities and where to access help and support. The multi-faceted program engages a peer education model to train and support 48 culturally and linguistically diverse young women aged between 18 and 24 years to become primary prevention ‘youth ambassadors.’ Once trained, the peer educators co-deliver education sessions to young people aged 18 to 24 and senior primary school students aged 10 to 13 years. You, Me and Us is supported by an expert advisory group with representatives from the university sector, youth services, ethno-specific organisations, the sports sector and services that work in the primary prevention of violence against women. The respectful relationship education session is delivered in target settings that include youth organisations, TAFEs and universities, sporting clubs and to senior primary school students in the western metropolitan region of Melbourne. To support the efficacy and sustainability of the education program, professional development training is provided to adult leaders in the target settings. You, Me and Us has a comprehensive evaluation framework. The University of Queensland undertake the external evaluation that includes pre and post questionnaire surveys for participants. WHW has also contracted the Australian Research Centre in Sex, Health and Society to evaluate all components of the program.

International Women’s Day To hold International Women’s Day (IWD) events that celebrates women’s diversity and Objective strengths, and increases awareness of violence against women and how to prevent it. Violence against women is caused by unequal power relations between women and men and adherence to gender stereotypes. WHW’s IWD events focus on celebrating women in Social and the west. This socially inclusive event celebrates the achievements and talents of women as behavioural part of a long process that is working toward changing the unequal power relations and determinants cultural norms that cause men to perpetrate violence against women, and the social structures that excuse it. Women who work, live or play in Melbourne’s western region. WHW’s 2014 International Population target Women’s Day event will have a specific focus on engaging young women from the western group region Program partners Program partners include local government, community health, youth services and the arts sector. WHW will continue to strengthen effective partnerships with the above organisations by organising bi-yearly IWD events. In 2014 the event will involve performances by local young Health promotion women to provide them with an opportunity to inspire and motivate others through creative actions and settings performance, increase their confidence, expand social networks and support their participation in the community. We will also screen the documentary, I am a girl, to raise awareness of the impact young women can have in the world. Evaluation WHW will evaluate the project through a narrative reflection of interested participants, evaluation forms and the level and type of social media/traditional media engagement.

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