Mark T Dooris

Holistic and sustainable health improvement: the contribution of the settings-based approach to health promotion

Highlighting the need for holistic and sustainable health improvement, this paper starts by reviewing the origins, history and conceptualization of the settings approach to health promotion. It then takes stock of current practice both internationally and nationally, noting its continuing importance worldwide and its inconsistent profile and utilization across the four UK countries. It goes on to explore the applicability and future development of settings-based health promotion in relation to three key issues: inequalities and inclusion; place-shaping and systems-based responses to complex problems. Concluding that the settings approach remains highly relevant to 21st century public health, the paper calls on the new “Royal� to provide much-needed leadership, thereby placing settings-based health promotion firmly on the national agenda across the whole of the UK.

Joining up settings for health: a valuable investment for strategic partnerships?

The concept and practice of healthy settings has developed over the past 17 years, to become a key element of public health strategy. However, there remains limited consensus about either theory or practice, and there has been little critical debate concerning the value of the approach in delivering public health. Furthermore, many settings initiatives have developed in isolation from others, with little concern to formulate an integrated vision or to ensure that their contribution is effectively harnessed. Drawing on the work of the North West Healthy Settings Development Unit, this paper provides an overview of the history, theory and practice of healthy settings, outlines the English policy context, makes a number of observations pertinent to future development, and concludes with a discussion of opportunities and challenges. It is suggested that healthy settings have the potential to provide a tangible ‘joined-up’ delivery route for local strategic partnerships, thereby maximizing their contribution to public health. However, in order to realize this potential, it is argued that local strategic partnerships need to think ‘outside of the box’, that healthy settings initiatives need to work towards a ‘whole systems’ model of practice and see themselves as springboards for wider corporate citizenship, and that bridges need to be built between work in various settings. Only then will the settings approach fully embrace its holistic and radical roots, ensuring an integrated and effective contribution to environmental, economic and social well-being, not only at a local level, but regionally, nationally and globally.

Community participation and empowerment in Healthy Cities.

Community participation and empowerment are core principles underpinning the Healthy Cities movement. By providing an overview of theory and presenting the relevant findings of evaluations, this article explores how cities in the WHO European Healthy Cities Network have integrated community participation and empowerment within their development. Reflecting the inclusion of public participation and empowerment within the designation criteria for project cities, the evaluation of Phase III in 2002 demonstrated that community participation continues to be a high priority in most project cities. One-third of cities regularly consulted with large parts of their populations and another third undertook occasional consultations. Nearly 80% of cities had mechanisms for community representatives to participate in decision-making; and more than two-thirds of cities had initiatives explicitly aimed at empowering local people. Subsequent research carried out during 2005 further highlighted the centrality of public participation to the Healthy Cities movement. It found that all project cities continued to support community involvement. Community participation is an essential part of the process of good local governance, and empowerment remains at the heart of effective health promotion. To be meaningful, these processes must be seen as fundamental values of Healthy Cities and so must be developed as an integral part of long-term strategic development.

The “Health Promoting University”: a critical exploration of theory and practice

As settings‐based health promotion has gained ascendancy within the field, there has been increased interest in applying the approach within a diversity of contexts, one of the most recent being higher education. The University of Central Lancashire became one of the first few universities in Europe to establish a Health Promoting University initiative when it appointed a co‐ordinator in 1995. This article critically discusses the emergence of the settings‐based approach to health promotion and its application to the higher education sector. Focusing on the University of Central Lancashire as a case study, it considers the development of Health Promoting Universities. It is argued that while the settings‐based approach still faces the challenge of establishing clarity and consistency, the Health Promoting University does have the potential to provide a robust conceptual framework that can enable the practical development and implementation of an holistic, comprehensive and integrative approach to promotin...

Healthy universities—time for action: a qualitative research study exploring the potential for a national programme

Despite the absence of national or international steers, there is within England growing interest in the Healthy University approach. This article introduces Healthy Universities; reports on a qualitative study exploring the potential for a national programme contributing to health, well-being and sustainable development; and concludes with reflections and recommendations. The study used questionnaires and interviews with key informants from English higher education institutions and national stakeholder organizations. The findings confirmed that higher education offers significant potential to impact positively on the health and well-being of students, staff and wider communities through education, research, knowledge exchange and institutional practice. There was strong support for extending the healthy settings approach beyond schools and further education, through a National Healthy Higher Education Programme that provides a whole system Healthy University Framework. Informants argued that although there are important public health drivers, it will also be necessary to show how a Healthy Universities can help achieve core business objectives and contribute to related agendas such as sustainability. Two models were discussed: an accreditation scheme with externally assessed standardized achievement criteria; and a flexible and light-touch framework focusing on change-related processes and utilizing self-assessment. While highlighting the appeal of league tables, many informants feared that a top-down approach could backfire, generating resistance and resulting in minimal compliance. In contrast, the majority felt that a process-focused aspirational model would be more likely to win hearts and minds and facilitate system-level change. Key recommendations relate to national programme development, research and evaluation and international collaboration and networking.

A green and healthy future: the settings approach to building health, equity and sustainability

As we move further into the twenty-first century, there is growing realization that the relationship between humans and the wider environment is crucially important, and a recognition that unfettered globalization linked to an increasingly dominant consumer culture has wrought devastating impacts. Within this context, and catalyzed particularly by concerns about climate change, there has also been increased appreciation that public health and the health of the planet are closely interrelated. This article focuses on the opportunities and potential value of encouraging joined-up thinking and integrated action in the settings where people live their lives. Having set the broad context regarding health, equity and sustainability, we scope current activity in relation to ‘greening’ settings before honing in on two concerns: that few such initiatives reflect the holistic and ecological perspective that underpins a settings approach to health promotion, and that work on sustainability and work on health have largely been developed in parallel rather than in an integrated manner. Having discussed these concerns, we propose six principles for progressive practice as a means of grounding a healthy and sustainable settings approach, before concluding by looking to the future and highlighting the likely need and benefits of daring to make more radical changes to our individual, community and working lives.

Health promoting settings: future directions

In 1986, the Ottawa Charter (WHO, 1986) declared that «Health is created and lived by people within the settings of their everyday life; where they learn, work, play and love.» The charter is widely acknowledged to have been the catalyst to the health promoting settings movement – resulting in the settings approach becoming the starting point for WHO’s health promotion programmes, with a commitment to «...shifting the focus from the deficit model of disease to the health potentials inherent in the social and institutional settings of everyday life» (Kickbusch 1996: 5).

Healthy Cities: Facilitating the Active Participation and Empowerment of Local People

Community participation and empowerment are key values underpinning the European WHO Healthy Cities initiative, now in its fifth phase. This paper provides a brief overview of the history, policy context, and theory relating to community participation and empowerment. Drawing on Phase IV evaluation data, it presents the findings in relation to the four quadrants of Davidson’s Wheel of Participation—information, consultation, participation in decision making, and empowerment. The large majority of European Healthy Cities have mechanisms in place to provide information for and to consult with local people. Most also demonstrate a commitment to enabling community participation in decision-making and to empowering citizens. Within this context, the evaluation highlighted a diversity of approaches and revealed varied perspectives on how participation and empowerment can be integrated within city leadership and governance processes. The paper concludes by suggesting that there is a need to strengthen future evaluative research to better understand how and why the Healthy Cities approach makes a difference.

Theorizing healthy settings: a critical discussion with reference to Healthy Universities

The settings approach appreciates that health determinants operate in settings of everyday life. Whilst subject to conceptual development, we argue that the approach lacks a clear and coherent theoretical framework to steer policy, practice and research. Aims: To identify what theories and conceptual models have been used in relation to the implementation and evaluation of Healthy Universities. Methods: A scoping literature review was undertaken between 2010 and 2013, identifying 26 papers that met inclusion criteria. Findings: Seven theoretical perspectives or conceptual frameworks were identified: the Ottawa Charter; a socio-ecological approach (which implicitly drew on sociological theories concerning structure and agency); salutogenesis; systems thinking; whole system change; organizational development; and a framework proposed by Dooris. These were used to address interrelated questions on the nature of a setting, how health is created in a setting, why the settings approach is a useful means of promoting health, and how health promotion can be introduced into and embedded within a setting. Conclusions: Although distinctive, the example of Healthy Universities drew on common theoretical perspectives that have infused the settings discourse more generally. This engagement with theory was at times well-developed and at other times a passing reference. The paper concludes by pointing to other theories that offer value to healthy settings practice and research and by arguing that theorization has a key role to play in understanding the complexity of settings and guiding the planning, implementation and evaluation of programmes.

Healthy Universities: current activity and future directions - findings and reflections from a national-level qualitative research study

This qualitative study used questionnaires to scope and explore ‘healthy universities’ activity taking place within English higher education institutions (HEIs). The findings revealed a wealth of health-related activity and confirmed growing interest in the healthy universities approach — reflecting an increasing recognition that investment for health within the sector will contribute not only to health targets but also to mainstream agendas such as staff and student recruitment, experience and retention; and institutional and societal productivity and sustainability. However, they also suggested that, while there is growing understanding of the need for a comprehensive whole system approach to improving health within higher education settings, there are a number of very real challenges — including a lack of rigorous evaluation, the difficulty of integrating health into a ‘non-health’ sector and the complexity of securing sustainable cultural change. Noting that health and well-being remain largely marginal to the core mission and organization of higher education, the article goes on to reflect on the wider implications for future research and policy at national and international levels. Within England, whereas there are Healthy Schools and Healthy Further Education Programmes, there is as yet no government-endorsed programme for universities. Similarly, at an international level, there has been no systematic investment in higher education mirroring the comprehensive and multifaceted Health Promoting Schools Programme. Key issues highlighted are: securing funding for evaluative research within and across HEIs to enable the development of a more robust evidence base for the approach; advocating for an English National Healthy Higher Education Programme that can help to build consistency across the entire spectrum of education; and exploring with the World Health Organization (WHO) and the International Union for Health Promotion and Education (IUHPE) the feasibility of developing an international programme. (Global Health Promotion, 2010; 17(3): pp. 6—16)