The most important task facing the health promotion sector is to help humanity change how we live in order to address “the converging crises of environmental degradation, climate change, resource depletion and social injustice”.
Professor Dooris, Reader in Health and Sustainable Development and Director of the Healthy Settings Unit at the University of Central Lancashire, dared the health promotion sector to “envision a different future and to change the way we conceptualise, organise and live our individual, community and working lives”.
He urged conference delegates to develop “an ecological perspective” and identify “what makes places liveable, vibrant and enriching” so this can be applied “to the settings of everyday life”.
Professor Dooris said:
“In looking to such a future, it will be important to focus not only on the negatives – the very real risks and ‘doom and gloom’; but also on the positives – re-engaging with the environment and the wonder of the world around us; and recognizing that within upheaval lie the seeds of hope and empowerment, and the potential for us to engage and embrace the emergence of new possibilities for enhancing the wellbeing of place, people and planet.“
He suggested that the health promotion sector needs “to step outside of our comfort zone and engage with and learn from the movements for social justice, sustainable futures and community resilience that have truly become ‘viral’, such as Transition Towns and Occupy”.
He said: “These have clearly captured people’s imagination and tapped into the zeitgeist or spirit of the age – and are where some of the most exciting change is happening. There’s huge potential for us to build partnerships to tackle some of our most taxing issues.”
Professor Dooris also urged conference delegates to deepen their socio-political analysis, and to work with stakeholders and communities to enable them to better understand the wider determinants of health, sustainability and injustice.
The sector should build on strengths and successes – “this means looking for assets and capacities within communities and organisations, rather than focusing only on needs and deficits”.
And he stressed the importance of engaging in advocacy aimed at harmonising environmental, social and economic demands, and at pressing governments, multi-nationals and global organizations “to act for health, sustainability and social justice”.
Professor Dooris, who is also Visiting Professor in Wellbeing at London South Bank University, was presenting by video and his talk was also delivered at a health promotion conference in Norway today.
A lightly edited version of his presentation follows below.
Healthy, sustainable and connected settings for the 21st Century
Mark Dooris writes:
Given the focus of my talk, it’s probably no bad thing that I’m connecting with you virtually instead of flying across the globe.
When looking at the logistics of me speaking at your conference, we quickly realised that a live link would require me to say something coherent in the middle of the night, so we decided to be pragmatic and opt for a pre-recorded presentation.
I want to start by setting the scene, looking at people and planet in relation to health, sustainability and social justice. I’ll then move on to look at place in terms of healthy settings, reflecting on the journey we’ve taken in health promotion, focusing in on theory and practice and the lessons we’ve learned over more than a quarter of a century.
I’ll then look forward – highlighting what I see as the implications, challenges and principles for practice involved in adopting an holistic and integrated approach to creating healthy, sustainable and connected settings.
It won’t be news to most of you that, globally, there are huge inequalities in health between different countries. We also experience stark health inequalities within societies, which are the result of social injustice.
Increasingly used in tandem with the term resilience, sustainability is commonly understood to be about our capacity to maintain or improve quality of life and to endure into the future.
Crucial to this is a commitment to social and environmental justice both within our own generation and between our own and future generations – and to harmonizing environmental, social and economic demands… our economic and social development ultimately takes place within the carrying capacity of our planet and its supporting ecosystems.
Respect the planet
This echoes what the Ottawa Charter’s called reciprocal maintenance, reminding us that if our planet is to support human life and wellbeing, then we need to treat it with respect. Crucial to this is a commitment to social and environmental justice both within our own generation and between our own and future generations – and to harmonizing environmental, social and economic demands
Climate change is perhaps the most high profile sustainability issue. Whilst the science of global warming is complex and contested, there is a huge body of evidence suggesting that climate change is happening.
Furthermore, an analysis of peer-reviewed papers by John Cook from the University of Queensland showed that of the 4,000-plus articles that took a position on the causes, 97% agreed that there is an important anthropogenic component through human activity. Another recent paper by Otto and colleagues concludes that whilst the short-term temperature rise may be slower than previously expected, the long-term scenario is as worrying as ever.
We’re all familiar with images showing a rise in sea levels and the melting of polar caps, but it’s perhaps less widely known that climate change is now commonly understood to be the biggest threat to human health. We also know that it will be the poor, the vulnerable and the marginalized who will be worst hit by the negative impacts.
In scoping the context of people and planet, there are harrowing things to consider. However, the connections between sustainability and health are not only negative – and it’s important to appreciate the positive impacts of the environment.
Starting with the wellbeing of the planet, we know that green space and natural environments can play an important role in storing carbon and reducing CO2 emissions, in controlling flooding and in sustaining biodiversity.
However, there is also a significant and strengthening body of evidence describing how nature and green space are beneficial to human health. Studies have shown that access to nature and green space is associated with enhanced mental wellbeing, reduced violence and aggression, and increased levels of physical activity; that ‘green exercise’ – exercise taken outdoors – is more beneficial than gym-based physical activity; and that patients in hospital recover more quickly if they have views of the natural environment from their window.
Again, we also know that access to green space mirrors other indicators of deprivation and is strongly related to health inequalities.
Richard Louv, in his book, ‘Last Child in the Woods’, speaks of ‘nature deficit disorder’ and the particular importance of reconnecting young people with nature.
He discusses the disturbing shifts created by a complex of factors such as the rise in screen-based entertainment and increased parental fear of unregulated spaces. He observes that whilst children may be aware of global threats to the environment, their close contact with nature is fading…”[they] can likely tell you about the Amazon rain forest – but not about the last time he or she explored the woods in solitude, or lay in a field listening to the wind and watching the stars move.”
Louv also contends that respect for the planet and a passion for sustainability and environmental activism are often borne out of the intimate contact with nature that has been so eroded.
The settings approach
Having briefly set out the context for connecting health, sustainability and social justice agendas in relation to people and planet, I now want to shift the focus onto ‘place’ by looking at what’s become known as the ‘settings approach’.
We all spend time in a range of different places and it’s clear that they have important influences on our wellbeing. Settings such as schools and workplaces have long been used by health promotion professionals as convenient vehicles for targeting interventions.
Understood in this way, settings – together with population groups and health topics or problems – make up the traditional three-dimensional matrix used to organise health promotion programmes, particularly those concerned with encouraging individual behaviour change.
However, what’s become known as the ‘settings approach’ moves beyond this fairly mechanistic view, appreciating that the contexts or places in which people live their lives are themselves crucially important in determining health.
The settings approach has developed over nearly 30 years to become a key element of health promotion strategy at local, national and international levels.
It has its roots within WHO’s Health for All strategy and, more specifically, the Ottawa Charter, which contended that: “health is created and lived by people within the settings of their everyday life; where they learn, work, play and love…Health is created by…ensuring that the society one lives in creates conditions that allow the attainment of health by all its members.”
Subsequent conferences and declarations further legitimized the approach, affirming that particular settings offer an effective infrastructure for the implementation of comprehensive strategies for health promotion – as witnessed by an expanding range of programmes, networks and strategies covering a diversity of settings.
Reflecting on this expansion, Ilona Kickbusch has commented that the ‘settings approach’ became during the 1990s the starting point for WHO’s lead health promotion programmes, which involved a shift of focus from the deficit model of disease to ‘salutogenesis’, concerned to foster the health potentials inherent in the social and institutional settings of everyday life – and so support wellbeing and human flourishing.
Whilst the WHO glossary defined a ‘setting for health’ as the social context in which people interact to affect wellbeing and create or solve problems relating to health – it’s also clear that most settings are in reality oriented to goals other than health and have pre-existing structures, policies, characteristics and institutional values.
It follows that the settings approach involves:
- a focus on structure and agency (and place and people)
- an understanding of a setting not only as a medium for reaching ‘captive audiences’ but also as a context that directly and indirectly impacts wellbeing; and
- a commitment to integrating health within the culture, structures and routine life of settings.
So why use the approach?
Whilst the provision of ‘health’ services is vitally important, our health is largely determined by social, economic, environmental, organisational and cultural circumstances – which directly impact wellbeing and also have indirect influences through providing more or less supportive contexts within which people make lifestyle choices.
It follows that effective health promotion and improvement requires investment in the places in which people live their lives.
More specifically, the approach recognises that people’s lives are complex and that the processes of enabling human flourishing and addressing 21st century health challenges are equally complex – requiring us to engage with what’s been characterised as ‘wicked’ problems.
Complexity requires us to embrace holism and emergence, appreciating that the patterns and system-related behaviours relating to these challenges are not predictable, are not linear and cannot be understood through reductionist analysis.
This means that the underlying influencing factors and conditions are interrelated and can be most effectively tackled not by ‘single thread’ interventions, but through comprehensive, integrated programmes in the settings of everyday life – where people learn, work, play, love, live and die.
Conceptually, the settings approach is rooted in health promotion values such as equity, partnership, participation and empowerment – and has three overarching characteristics.
Firstly, it adopts an ecological model. It appreciates that health is multi-layered and determined by a complex interaction of factors; it focuses on populations within particular contexts; it represents a shift of focus towards an holistic and salutogenic view; and it addresses human health within the context of ecosystem health.
Secondly, the approach views settings as complex systems, acknowledging interconnectedness and synergy between different components, and recognising that each setting is connected to the world around it.
Thirdly, the approach adopts a whole system focus, drawing on learning from organisation and community development and using multiple, interconnected interventions to embed health within the culture and ethos of settings that generally do not have health as their ‘raîson d’être’.
This means harnessing the multi-dimensional nature of settings – and, within this, the relationship between the structural dimension provided by their contexts, facilities, services and programmes, and the human agency of the people within them – to create healthy, supportive and sustainable environments; integrate health into routine life and core business (whether this is quality of patient care in hospitals; education in schools; or rehabilitation in prisons); and connect with and contribute to the wellbeing of the wider community.
This model illustrates the balances involved in implementing a whole system approach. It reminds us that the approach is underpinned by core health promotion values, draws on a diverse portfolio of methods and involves holding a number of aspects in tension: addressing needs and problems, but also seeking to celebrate and build on strengths and capabilities; investing in long-term ‘behind the scenes’ organization development, but retaining a high profile through managing innovative and visible projects; securing top-down leadership alongside bottom-up empowerment and broad-based ownership; and anticipating and responding to public health concerns whilst also being driven by and contributing to mainstream business.
Lessons since the Ottawa Charter
Having outlined the background to, set out the rationale for, and sketched a conceptual framework for understanding and implementing the settings approach, I want to step back and consider what we’ve learnt in the decades since the Ottawa Charter.
The first lesson is that there is a diversity of activity happening under the banner of what is variously labelled settings-based health promotion, health promoting settings, healthy settings and settings for health.
Whilst diversity can be a strength, it can also indicate a lack of clarity, which this varied terminology perhaps symbolises. I’d suggest that it also reflects a tendency to shy away from, rather than embrace, complexity.
In their 2001 paper, Sandy Whitelaw and colleagues presented a typology of different models of settings activity. Whilst they acknowledge that it is not always possible to implement a fully comprehensive approach, they support Wenzel’s earlier critique, arguing that those claiming the settings label need to do more than repackage interventions focused on individual behaviour change – a view reinforced by Johnson and Baum in relation to health promoting hospitals.
The second lesson is that whilst there is value in articulating an overarching framework to guide implementation, settings are not all the same and exist in relation to each other. When we talk about a ‘health promoting school’, a small primary school presents very different challenges to a large secondary school; and when we talk about workplaces, we not only have to consider businesses ranging from small and medium enterprises to huge multinationals, but also how workplace health is addressed as a crucial feature of our programmes in healthcare, educational, criminal justice, leisure and other settings.
Furthermore, there are clear differences between categories of settings – for example institutions such as hospitals and universities are very different from less formal ‘geographical’ settings such as neighbourhoods and homes, yet all of these are nested within – and contribute to the wellbeing of – cities, towns and municipalities.
The third lesson is that the settings approach risks reinforcing power imbalances and perpetuating inequalities – and it is important to engage critically with the structure and agency debate.
Green, Poland and Rootman caution against programmes uncritically aligning themselves with management: whilst the approval and commitment of such gatekeepers may be important in gaining access to a setting and influencing organisational change, it may unintentionally play into existing power relations and make it difficult to engage and gain the trust of other stakeholders.
They also echo Galbally in drawing attention to the danger that by focusing on well-defined organizational settings, we miss many of the most vulnerable and disenfranchised groups of the population – such as the unemployed, the homeless, asylum seekers and children who are excluded from school.
This highlights the importance of further developing work with settings such as prisons and children’s care homes, and of locating settings-focused work within the context of a broader health promotion framework – it’s only part of the solution!
And the fourth lesson is that health is closely related to other agendas and concerns and that there is value in moving beyond the boundaries of traditional health promotion.
This realization is one that I’ve already highlighted in the context for my presentation and one that has become increasingly apparent in the context of globalization and in discussions about ‘liveability.’
For example, the report Our Cities, Our Future reflected that “liveability refers to the way the…environment supports the quality of life and wellbeing of communities. Quality of life and wellbeing encompasses mental and physical health, happiness and life satisfaction for individuals and supportive social relationships in communities…[and] is enhanced by environmental sustainability.”
In responding to this learning, I’d suggest that we need to reflect on our experience to date and forge a new praxis for healthy, sustainable and connected settings that is holistic and integrated. So, what are the implications?
A call to clarify values and theory
First, it means ‘connecting practice, theory and research’. When undertaking my doctoral study, many of those involved in the emergence of healthy settings reflected that, whilst informed by ecology, holism, salutogenesis and systems thinking, the approach has lacked a theoretical framework – a concern that Jane Wills, Jo Newton and I will be exploring in a workshop following this session.
I’d suggest that we can strengthen practice and implementation through clarifying both values and theory – and that we need to be explicit about what our settings initiative is aiming to achieve and how we expect this initiative and its multiple interventions to achieve those aims.
Closely linked to this, we need to find ways to move beyond evaluating the individual interventions taking place in a setting, to capture the added value of adopting and implementing an ecological whole system approach.
Whilst there have been calls to move beyond linear evaluation and engage with complexity through utilising realist and theory-based approaches, there are still relatively few examples of research that has successfully grasped this ‘nettle’.
Second, it means ‘connecting within’ the setting. Specifically, this will require us to connect top-down leadership with bottom-up participation … daring to combine senior leadership with unleashing the richness of grassroots creativity and innovation – ensuring that, in the words of Ilona Kickbusch, “settings provide a political space for empowerment.”
More generally, it will mean appreciating and mapping the linkages that exist in any one setting. To illustrate this with reference to a school, our focus might be on connecting between… different groups of people or different topics or issues or different components of the system.
Third, it means ‘connecting outwards’, appreciating that settings are interlinked. People’s lives straddle different settings – both at a specific point in time and, as Dean Whitehead has discussed, across the life course.
Similarly, the 21st century challenges facing us – such as climate change and obesity – do not respect boundaries. Furthermore, these boundaries have become increasingly permeable: a problem made manifest in one setting may well have its roots in a different setting which, in the case of an issue such as bullying in school, is increasingly likely to be virtual or online as well as within the geographical community.
Connecting settings with wider systems
This means that there is value in connecting settings with their wider systems – appreciating that initiatives with discrete settings can be a springboard for expanding the work, for example from health promoting schools and health promoting hospitals…
…to health promoting kindergartens and universities and health promoting health and social care services.
Settings also exist at different levels, often within the context of each other. For example, a hospital or school may be within a particular neighbourhood, within a town or city, within a district, region or island, within a country – with the planet being the overarching contextual setting.
This echoes Bronfenbrenner’s work on social ecology, in which he suggests that human development takes place in micro, meso and macro settings within a number of interconnected layers.
This understanding reinforces the need for settings initiatives to respect and care for the earth – but also has implications for the conceptual and practical organization of different programmes.
In one of my interviews, Agis Tsouros from the WHO Regional Office for Europe said “a Healthy City should be a city of healthy settings,” highlighting the need to view individual settings as part of a bigger whole and work to enhance the synergy between them and maximise their contribution to the well-being of municipalities.
Whilst we can make some progress developing a ‘whole system’ healthy and sustainable food strategy or travel plan for a specific setting such as a hospital or a university, a truly holistic approach demands that we have joined-up strategies across settings.
However, whilst certain WHO regions have at times worked with ‘families’ of settings within the overarching frameworks offered by Healthy Cities, Healthy Districts or Healthy Islands, bureaucratic structures and competing egos have too often intervened and stopped this from happening.
Fourth, it means ‘connecting upwards’ – acknowledging that whilst action focused within and across settings is important, there are higher level influences at play.
In looking upwards, we can examine our work to ensure that it is doing all it can to tackle the wider determinants of health and ill-health – and integrate health equity impact assessment into our planning and delivery of settings programmes, as was urged in the final report of the Commission on Social Determinants of Health.
Beyond this, however, part of our task must be advocacy – calling on governments, multi-nationals and global organizations to act for health, sustainability and social justice.
And fifth, an holistic approach also means ‘connecting beyond health’ – explicitly linking the health of people and the health of the planet, and prioritizing and using as exemplars place-based actions that engage with both health and sustainability concerns.
I want to pick up on this last point and revisit the territory that I touched on at the start of my presentation – considering why we should connect health and sustainability in relation to settings. I’d suggest that there are at least three reasons…
First, health is both a critical outcome of and prerequisite for environmentally, socially and economically sustainable development – and we are most likely to see healthy and sustainable settings when we do not view economic development as an end in itself, but hold these three spheres of action in balance, promoting places that are viable, liveable and equitable.
Second, the causes and manifestations of unsustainable development and poor health are interrelated, pose interconnected challenges and offer potential for ‘win-win’ synergistic solutions. For example, there is enormous synergy between climate change and obesity…
This relates both to their roots in underpinning metabolic imbalance and in the range of actions and policy interventions that can be taken to tackle both, with wider knock-on effects.
Thus, good spatial planning catalysed by Healthy City initiatives can increase levels of physical activity and increase access to healthy and locally-produced food, which in turn can help to tackle obesity and non-communicable diseases; enhance mental wellbeing; and reduce carbon emissions through decreased car use and lower food miles.
Third, the health of people, places and the planet are interdependent. This can be understood in a number of ways: for example, as I’ve already highlighted, there is a growing body of evidence demonstrating the positive impacts of nature and green space on human wellbeing; and there is likewise a wealth of research showing how the deterioration of ‘planetary health’ poses significant risks to the health of people.
In advocating for ecological public health, Tim Lang and Geof Rayner argue convincingly that “the interface of human and ecosystems health now deserves to be central for policy making.”
Picking up this last point, it’s widely acknowledged that we face a significant ‘triple threat’ from environmental degradation, climate change and resource depletion.
This threat is closely connected to societal greed and to a continued infatuation with unfettered growth (which begs the question for many as to whether we can coherently link the words ‘sustainable’ and ‘development’).
Relating these concerns to health, we also know that increased material wealth does not automatically translate into increased wellbeing – and Phil Hanlon from Glasgow University has highlighted the threat that consumer culture poses to both humans and the long-term sustainability of the planet – suggesting that the public health community has a vital role to play in working creatively to imagine and bring about an approach that enables us to ‘use less stuff’ and have better health and wellbeing.
It’s also clear that these threats contribute to and are closely entwined with growing socio-economic inequalities, poor health status and increasing inequities in health – making it imperative that policies for health and sustainability are integrated and that social justice is understood to be inextricably linked to environmental justice.
So, what have the responses been?
At an individual level, we’ve seen an increasing market for ‘green consumerism’ and a concern with reducing ‘carbon footprints’.
At community and city levels, there has been a growing focus on activism and mobilisation, often around specific issues.
At an organisational level, there has been a surge in the development of frameworks and standards for corporate environmental (and social) responsibility in a diversity of settings – accompanied by expanding rhetoric and action concerned to promote sustainability through ‘greening’ organisational behaviour, whilst increasing productivity and securing a market advantage.
These responses have evidently led to what can be termed the ‘greening’ of settings through institutional practices and community and city-level governance related to a range of issues.
Ecological determinants on the sidelines?
However, I’d suggest that health promotion has tended to focus so strongly on social determinants of health that ecological determinants risk being sidelined.
Despite a growing appreciation of the health benefits of increased access to nature, and of carbon reduction and climate change mitigation and adaptation, action for ‘sustainability’ and ‘health’ have tended to happen in parallel – perpetuating what Trevor Hancock has called a ‘multiple-silo’ approach.
Furthermore, many ‘greening’ initiatives, like many health promotion initiatives, tend to be ‘add-ons’, delivering fragmented lifestyle interventions within settings rather than reflecting an ecological whole system approach.
Before concluding, I want to expand on some work I did with Blake Poland to suggest some principles for practice that could underpin an holistic and integrated approach to creating healthy, sustainable and connected settings.
Take a positive look to the future
First, dare to envision the future we want – adopting an ecological perspective and identifying what makes places liveable, vibrant and enriching, then taking this diagnosis and applying it to the settings of everyday life.
In doing this, we may need to let go of the explicit language of health – but may find new ways to facilitate innovative and creative change and help build sustainable and connected settings that enhance human and ecosystem wellbeing.
Second, whilst holding on to this ‘big’ vision of what healthy and sustainable settings can and should be, take smaller incremental steps towards realizing that vision – finding ‘entry points’ where we can secure both top-down commitment and bottom-up engagement.
Third, start where people are…This means listening to and respecting people and negotiating agendas, balancing the urgency of our priorities with a willingness to value other concerns and build shared ownership – and understanding that different people see the world through different ‘lenses’.
Fourth, build on strengths and successes…this means looking for assets and capacities within communities and organisations, rather than focusing only on needs and deficits – and learning from, harnessing and connecting the things that are already working effectively.
Fifth, root practice in place…this means that whilst the settings approach seeks to stay true to common values and characteristics, it also appreciates the distinctiveness of different settings and the need to take account of different cultures, structures and histories when we develop and implement initiatives – as highlighted by Poland, Krupa and McCall in their framework designed to guide design and delivery.
Sixth, build resilience within and between settings – recognising that narrowly-defined notions of efficiency have often led to its erosion. This focus is prominent in grassroots initiatives such as Transition Towns, and leads on to the next principle…
…which is to engage with and learn from emerging social movements.
Looking back at the literature in the immediate aftermath of the Ottawa Charter, settings-focused programmes such as Healthy Cities were talked about as new and exciting social movements for health…
Twenty years on, they are, arguably, at risk of becoming institutionalised, professionalised and bureaucratised – and I’d suggest that we need to step outside of our comfort zone and engage with and learn from the movements for social justice, sustainable futures and community resilience that have truly become ‘viral’, such as Transition Towns and Occupy.
These have clearly captured people’s imagination and tapped into the zeitgeist or spirit of the age – and are where some of the most exciting change is happening. There’s huge potential for us to build partnerships to tackle some of our most taxing issues.
Last, revisiting the importance of advocacy, we need to deepen our socio-political analysis…this means shifting our focus beyond symptoms to root causes; and at the same time supporting processes akin to what Paolo Freire called ‘conscientisation’ – working with stakeholders and communities within and across different settings to enable them to develop critical consciousness about the wider determinants of health, sustainability and injustice; to connect their lived experience to that of others and to the wider practices and structures that create and sustain exploitation of people and the world around us; and to become empowered to realize their agency and to advocate for and catalyse change.
To conclude…I’ve argued that – more than a quarter of a century after it was ushered in by the Ottawa Charter – the settings approach is still highly relevant and can make an important contribution to health, sustainability and liveability.
By adopting an holistic, integrated and connected approach, we have the potential to respond to the lessons we’ve learnt and the 21st century challenges we face – enhancing the relevance and effectiveness of initiatives in the diverse places in which people live their lives.
Isis Brook, formerly at UCLan, talks of the importance of “healing ourselves of our current alienation from nature and healing the earth from our alienated actions upon it.”
As the converging crises of environmental degradation, climate change, resource depletion and social injustice intensify, we will need to do more than ‘tick the right boxes’ – daring to envision a different future and to change the way we conceptualise, organise and live our individual, community and working lives.
In looking to such a future, it will be important to focus not only on the negatives – the very real risks and ‘doom and gloom’; but also on the positives – re-engaging with the environment and the wonder of the world around us; and recognizing that within upheaval lie the seeds of hope and empowerment, and the potential for us to engage and embrace the emergence of new possibilities for enhancing the wellbeing of place, people and planet.
Helping to nurture and midwife this transition is perhaps the most important task facing health promotion today.
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