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Some big challenges for health promotion (including the “converging crises” of environmental degradation and social injustice)

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”.

This was one of several challenges that UK expert Professor Mark Dooris issued to the Australian Health Promotion Association (AHPA) conference in Sydney today.

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.

Overarching characteristics

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