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Mark Dooris NHPRC 2013


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Place, People, Planet:
The Settings Approach to Health
Promotion: Lessons Learned and
Perspectives for the Future

Published in: Education, Technology
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Mark Dooris NHPRC 2013

  1. 1. Place, People, Planet: The Settings Approach to Health Promotion: Lessons Learned and Perspectives for the Future 17 June 2013 Mark Dooris ©MarkDooris
  2. 2. People & Planet: Health, Sustainability & Social Justice Place: The Settings Approach – Theory, Practice & Lessons Learnt An Holistic & Integrated Approach – Implications Reflections & Snapshots Perspectives for the Future: Principles for Practice
  3. 3. People & Planet: Health, Sustainability & Social Justice Place: The Settings Approach – Theory, Practice & Lessons Learnt An Holistic & Integrated Approach – Implications Reflections & Snapshots Perspectives for the Future: Principles for Practice
  4. 4. Health and Social Justice: Health Inequalities – World Life Expectancy at Birth
  5. 5. Sustainability Environment Society Economy
  6. 6. ―Most of the observed increase in global average temperatures over the last decades is very likely due to the observed increase in anthropogenic greenhouse gas emissions.‖ Intergovernmental Panel on Climate Change, 2007 Health and Sustainability: Climate Change ―The 'warming pause' over the recent decade does not show that climate change is not happening.‖ Sources: Cook et al, 2013, Otto et al, 2013
  7. 7. Health and Sustainability: Nature, Health and Wellbeing  Access to nature/green space associated with:  Reduced mental health problems  Enhanced mental wellbeing,  Reduced violence and aggression,  Increased levels of physical activity  ‗Green exercise‘ more beneficial than indoor activity  Views of nature beneficial for patients/others  Access to green space mirrors indicators of deprivation ©MarkDooris ©MarkDooris ©MarkDooris ©MarkDooris Sources: St Leger, 2003; Maller et al, 2006; FPH, 2010
  8. 8. Health and Sustainability: Nature, Health and Wellbeing ©MarkDooris ―Today, kids are aware of the global threats to the environment, but their physical contact, their intimacy 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, 2009
  9. 9. Health and Sustainability: Nature, Health and Wellbeing ―New maladies of the soul have emerged…complicated products of the distance we have set between ourselves and the world…The feel of a hot dry wind on the face, the smell of distant rain carried as a scent stream in the air…such encounters shape our being and our imaginations in ways which are beyond analysis, but also beyond doubt.‖ Macfarlane, 2007 ©MarkDooris ©MarkDooris ©MarkDooris ©MarkDooris
  10. 10. People & Planet: Health, Sustainability & Social Justice Place: The Settings Approach – Theory, Practice & Lessons Learnt An Holistic & Integrated Approach – Implications Reflections & Snapshots Perspectives for the Future: Principles for Practice
  11. 11. From…Settings as Dimension of Health Promotion Matrix To…The Settings Approach & Healthy Settings
  12. 12. Health for All 1977- Healthy Settings Ottawa Charter 1986 Healthy Cities 1997 Jakarta Declaration Bangkok Charter 2005 Sundsvall Declaration on Supportive Environments 1991 2007 Shaping the Future of Health Promotion Healthy Settings: Origins & Development Nairobi Declaration 2009 ―Health is created & lived by people within the settings of their everyday life; where they learn, work, play & love. Health is created by...ensuring that the society one lives in creates conditions that allow the attainment of health by all its members.‖ 2012 Health 2020 & NCD Action Plan
  13. 13. Healthy Settings: Origins & Development ©MarkDooris
  14. 14. Healthy Settings: Origins & Development ―The ‗settings approach‘ became the starting point for WHO‘s lead health promotion programmes…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 ©MarkDooris
  15. 15.  focus on structure and agency (and place and people)  understanding of a setting not only as medium for reaching ‗captive audiences‘ but also as context which impacts wellbeing  commitment to integrating health and wellbeing within the culture, structures and routine life of settings. Healthy Settings: What? Healthy settings approach involves: ©MarkDooris
  16. 16.  Whilst important, ‗health‘ services are only one factor influencing health  Health determined by range of economic, environmental, organisational and cultural circumstances – which have direct and indirect influences  Health promotion requires investment in the places (or ‗social systems‘) in which people live their lives Source: adapted from Grossman & Scala, 1993 Healthy Settings: Why?
  17. 17. Healthy Settings: Complexity ©MarkDooris Useful sources: Tremblay and Richard, 2011; Butland, et al, 2007
  18. 18. Healthy Settings: Conceptual Framework Ecological model of health Systems perspective Whole system change Values ©MarkDooris Sources: Dooris, 2005, Dooris et al, 2007 ©MarkDooris
  19. 19. Healthy Settings: Whole System Model Createhealthyandsustainableworking, learningandlivingenvironments Integratehealthintoroutinelifeandcore businessofthesetting Contribute to health, well-being and sustainability of the wider community SETTING Setting Physical Environment ‘Political’ and Economic Environment Cultural and Social Environments Facilities and Services Interventions and Programmes Other Settings and Wider Community SETTING Wider Social/Economic/Environmental Determinants Source: © Dooris 2013
  20. 20. Values e.g. participation, empowerment, equity, partnership, sustainability ‘whole system’ ecological settings approach institutional agenda & core business  public health agenda organisation/ community development & change  high visibility innovative projects top-down political/ managerial commitment  bottom-up engagement & empowerment Methods e.g. policy development/implementation, environmental modification, social marketing, peer education, impact assessment needs, deficits, problems (pathogenesis)  capabilities assets, potentials (salutogenesis) Healthy Settings: ‘Balance’ Model Source: © Dooris 2013, adapted from Dooris, 2004
  21. 21. Lesson 1: Diversity of practice carried out under settings ‘banner’ ―SETTINGS‖ Comprehensive/ Structural model Organic model Vehicle model Active model Passive model ―Those who do deploy a settings model need to ensure that their work is more than simply a superficial re-packaging of traditional individualistic health education in a particular setting.‖ Whitelaw et al, 2001 [see also Wenzel, 1997; Poland et al, 2000; Johnson & Baum, 2001]
  22. 22. Lesson 2: Different settings are distinct and exist in relationship to other settings  Value in articulating an overarching conceptual framework  Settings differ within categories (e.g. size/type of school or workplace)  Settings differ between categories (e.g. organisational vs geographical)  Settings exist in relation to – and are nested within – one another. Useful sources: Poland et al, 2000; Dooris, 2005; Poland, Krupa & McCall, 2009
  23. 23. Lesson 3: Risk of reinforcing power imbalances and perpetuating inequalities in health  Beware of inadvertently reinforcing power relationships  Recognise that settings approach may well exclude marginalised and disenfranchised groups that live their lives outside of ‗formal‘ settings  Undertake health equity impact assessments  Further develop work with settings such as prisons  Locate work within broader health promotion framework.
  24. 24. Lesson 4: Health closely related to other agendas – beyond ‘traditional’ health promotion ―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…[and] is enhanced by environmental sustainability, in particular with regard to low levels of pollution and access to quality open space and natural landscapes.‖ Australian Government, 2011
  25. 25. Intermission: Quiz A. 10% B. 30% C. 40% What proportion of global food production is either wasted or lost? How much more carbon intensive is beef production than wheat production? A. 5 times B. 10 times C. 20 times Net_Eleck/flickrr
  26. 26. People & Planet: Health, Sustainability & Social Justice Place: The Settings Approach – Theory, Practice & Lessons Learnt An Holistic & Integrated Approach – Implications Reflections & Snapshots Perspectives for the Future: Principles for Practice
  27. 27. Connect Practice, Theory & Research Acknowledgement:HealthySchools
  28. 28. Connect Within Settings ©MarkDooris
  29. 29. pupils teachers caterers wider community families governors Mapping Settings Connecting Between People Source: adapted from Dooris, 2005 Ackn: Healthy Schools
  30. 30. travel mental health physical activity advertising & sponsorship climate change food/diet Source: adapted from Dooris, 2005 Mapping Settings Connecting Between Issues Ackn: Healthy Schools
  31. 31. formal curriculum buildings & grounds transport infrastructure governance structures inter-personal relationships Mapping Settings Connecting Between Components procurement system Source: adapted from Dooris, 2005 Ackn: Healthy Schools
  32. 32. Connect Outwards ©MarkDooris
  33. 33. Source: adapted from Grossman and Scala, 1993 Schools Hospitals Prisons Workplaces Communities Sports Stadia IllnessHealth     Connect Outwards
  34. 34. Health & Social Care Services Criminal Justice Systems Economy Local & Virtual Communities Sport & Leisure IllnessHealth     Education Kindergarten : School Education College : University Connect Outwards
  35. 35. Connect Outwards Useful sources: Galea et al, 2000; Bronfenbrenner, 1979 ―A Healthy City should be a city of healthy settings.‖ Agis Tsouros, Personal Communication – Doctoral Research
  36. 36. Connect Upwards Ackn:HealthySchools
  37. 37. Connect Beyond Health
  38. 38. Why Healthy and Sustainable Settings? Health is both a critical outcome of and prerequisite for environmentally, socially and economically sustainable ‗development‘. Source: adapted from Source: Hancock, 1996 Economic Development Social SUSTAINABILITY ↕ HEALTH Viable Equitable Economic Liveable Environment
  39. 39. Why Healthy and Sustainable Settings? Causes and manifestations of unsustainable development and poor health are interrelated, pose interconnected challenges & offer potential for ‗win-win‘ synergistic solutions.
  40. 40. The health of places, people and the planet are interdependent. ―Human health ultimately depends on the health of ecosystems…the interface of human and ecosystems health now deserves to be central for policy making.‖ Lang & Rayner, 2012 Why Healthy and Sustainable Settings?
  41. 41. Human Health and Ecosystem Health: Equity Issues Environmental ‗triple threat‘ environmental degradation climate change resource depletion Growing socio-economic inequalities Poor health and increasing inequities in health Economic Growth Model Sources: Poland & Dooris, 2010; Poland, Dooris & Haluza-Day, 2011; Rao, 2009
  42. 42. Human Health and Ecosystem Health: Climate Change
  43. 43. Sustainability and Consumerism ―The public health community has a vital role to play in working creatively to imagine and...bring about an approach to life that enables all of us to ‗use less stuff‘ and have better levels of health and wellbeing.‖ Hanlon et al, 2012 Tony Biddle, 2010
  44. 44. Responses at Different Levels  Individual Level: increasing market for ‗green consumerism‘ and ‗carbon footprint reduction‘.  Community/City Level: increasing focus on issue-based activism and mobilisation.  Organisation Level: increasing focus on corporate environmental (and social) responsibility in range of settings – with rhetoric and action concerned to promote sustainability through ‗greening‘ organisational practices, whilst increasing productivity/performance and securing a market advantage. ©MarkDooris Source: Poland & Dooris, 2010
  45. 45. Greening Settings: Focus Areas Energy Water Other Resources Transport Food These responses have led to the ‗greening‘ of settings through organisational practices and local governance related to: Source: Poland & Dooris, 2010
  46. 46. Greening Settings: Reflections ―Something we...need to be a lot better at is avoiding ‗multiple silo‘ programmes...‖ Professor Trevor Hancock, Personal Communication – Doctoral Research
  47. 47. People & Planet: Health, Sustainability & Social Justice Place: The Settings Approach – Theory, Practice & Lessons Learnt An Holistic & Integrated Approach – Implications Reflections & Snapshots Perspectives for the Future: Principles for Practice
  48. 48. Connecting Health and Sustainability: Cities
  49. 49. Connecting Health and Sustainability: Cities
  50. 50. Connecting Health and Sustainability: Cities ©MarkDooris ©MarkDooris ©MarkDooris
  51. 51. Connecting Health and Sustainability: Universities
  52. 52. Connecting Health and Sustainability: Universities Ackn:SkyRide
  53. 53. Connecting Health and Sustainability: Universities
  54. 54. Connecting Health and Sustainability: Prisons and Criminal Justice
  55. 55. Connecting Health and Sustainability: Prisons and Criminal Justice
  56. 56. Connecting Health and Sustainability: Prisons and Criminal Justice
  57. 57. Connecting Health and Sustainability: Prisons and Criminal Justice
  58. 58. Connecting Health and Sustainability: Prisons and Criminal Justice ―You put the seed in the ground, it‘re caring for something. Something that isn‘t judgemental, something that will not answer back, something that will flourish with a bit of tender loving care…And it‘s a journey through life and it‘s like theirs, you know…When you start talking to the women about how often the flower reacts to how you care for it and grow it, you start realising – what if I look after my family that way, maybe I can make a difference, maybe I can make a change.‖ Horticultural Instructor, HMP & YOI Styal ©MarkDooris
  59. 59. People & Planet: Health, Sustainability & Social Justice Place: The Settings Approach – Theory, Practice & Lessons Learnt An Holistic & Integrated Approach – Implications Reflections & Snapshots Perspectives for the Future: Principles for Practice
  60. 60. 1. Adopt an ecological perspective ©MarkDooris
  61. 61. 2. Hold on to a big vision – take incremental steps ©MarkDooris©MarkDooris
  62. 62. 3. Start where people are ©MarkDooris
  63. 63. 4. Take an assets approach – build on strengths & successes ©MarkDooris
  64. 64. 5. Root practice in place – recognise distinctive cultures, structures & histories ©MarkDooris©MarkDooris
  65. 65. 6. Build resilience within & between settings ©MarkDooris
  66. 66. 7. Engage with & learn from social movements ©MarkDooris©MarkDooris
  67. 67. 8. Deepen socio-political analysis – causal focus & ‘conscientisation’ ©MarkDooris
  68. 68. Conclusions: Looking Into the Future ©MarkDooris
  69. 69. References and Further Reading  Australian Governmnet (2011) Our Cities, Our Future: A National Urban Policy for a Productive, Sustainable and Liveable Future. Canberra: Department of Infrastructure and Transport.  Bronfenbrenner, U. (1979) The Ecology of Human Development. Experiments by Nature and Design. Cambridge, MA: Harvard University Press.  Brook, I. The importance of nature, green spaces, and gardens in human wellbeing. Ethics, Place & Environment, 13: 295-312  Butland, B., Jebb, S.,Kopelman, P., McPherson, K., Thomas, S., Mardell, J. and Parry, J. (2007) Tackling Obesities: Future Choices – Project Report. London: Foresight Programme, Government Office for Science.  Commission on Climate Change (2009) Final Report: Managing the health effects of climate change: Lancet 373: 1693 - 1733.  Cook, J. et al (2013) Quantifying the consensus on anthropogenic global warming in the scientific literature. Environmental Research Letters 8(2) doi:10.1088/1748-9326/8/2/024024  Dooris, M. (2004) Joining up settings for health: a valuable investment for strategic partnerships? Critical Public Health 14: 49-61. Dooris, M. (2005) Healthy settings: challenges to generating evidence of effectiveness. Health Promotion International 21: 55-65.  Dooris, M. (2009) Holistic & sustainable health improvement: the contribution of the settings-based approach to health promotion. Perspectives in Public Health, 129: 29-36.  Dooris, M (2013) Bridging the Silos: Towards Healthy and Sustainable Settings for the 21st Century. Health & Place 20: 39-50.  Dooris, M., Poland, B., Kolbe, L., de Leeuw, E., McCall, D. & Wharf-Higgins, J. (2007) Healthy settings: Building evidence for the effectiveness of whole system health promotion – challenges & future directions. Chapter in D.V. McQueen & C.M. Jones (Eds.) Global Perspectives on Health Promotion Effectiveness. New York: Springer Science & Business Media, pp. 327-352. Galbally R. Health-promoting environments: who will miss out? Australian and New Zealand Journal of Public Health, 21: 429-30.  Faculty of Public Health (2010) Great Outdoors: How Our Natural Health Service Uses Green Space to Improve Wellbeing: An Action Report. London: FPH.  Galea, G., Powis, B. and Tamplin, S. (2000) Healthy islands in the Western Pacific – international settings development. Health Promotion International, 15: 169–178.  Griffiths, J., Rao, M., Adshead, F. and Thorpe, A. (Eds) (2009) The Health Practitioner’s Guide to Climate Change. Diagnosis and Cure. London: Earthscan.  Grossman, R. and Scala, K. (1993) Health Promotion and Organisational Development: Developing Settings for Health. Copenhagen: WHO Regional Office for Europe.  Hancock, T. (1996) Planning and creating healthy and sustainable cities: the challenge for the 21st century. In Price, C. and Tsouros, A. Our Cities, Our Future. Copenhagen: WHO Regional Office for Europe.  Hanlon, P,, Carlisle, S., Hannah, M. and Lyon, A. (2012) The Future Public Health. Maidenhead: Open University Press,  Intergovernmental Panel on Climate Change (2007) Fourth Assessment Report. Geneva: IPCC.
  70. 70. References and Further Reading  Johnson, A. and Baum, F. (2001) Health promoting hospitals: a typology of different organizational approaches to health promotion, Health Promotion International, 16(3): 281-287.  Kickbusch, I. (1996) Tribute to Aaron Antonovsky – ‗what creates health‘? Health Promotion International, 11(1), pp. 5–6.  Kickbusch, I. (2003) The contribution of the World Health Organization to a new public health and health promotion. American Journal of Public Health, 93: 383-388.  Lang, T. and Rayner, G. (2012) Ecological public health: the 21st century‘s big idea? BMJ 345, 17–20.  Louv, R. (2009) Last Child in the Woods. London: Atlantic Books  Macfarlane, R. (2007) The Wild Places. London: Granta.  Maller, C., Townsend, M., Pryor, A., Brown, P. and St Leger, L. (2006) Healthy nature healthy people: ‗contact with nature‘ as an upstream health promotion intervention for populations. Health Promotion International, 21: 45-54.  Orme, J. and Dooris, M. (2010) Integrating Health and Sustainability: the Higher Education Sector as a timely catalyst. Health Education Research, 25: 425-437.  Otto, A., et al (2013) Energy budget constraints on climate response. Nature Geoscience. doi:10.1038/ngeo1836  Poland, B. and Dooris, M. (2010) A green and healthy future: a settings approach to building health, equity and sustainability. Critical Public Health, 20: 281-298.  Poland, B., Dooris, M. & Haluza-Delay, R. (2011) Securing ‗supportive environments‘ for health in the face of ecosystem collapse: meeting the triple threat with a sociology of creative transformation. Health Promotion International 26 (Supplement 2): ii202-ii215.  Poland, B., Green, L. and Rootman, I. (Eds) Settings for Health Promotion: Linking Theory and Practice. Sage, London.  Poland, B., Krupa, G. and McCall, D. (2010) Settings for health promotion: an analytic framework to guide intervention design and implementation. Health Promotion Practice, 10: 505-16.  St Leger, L. (2003) Health and nature—new challenges for health promotion. Health Promotion International, 18: 173-175.  Stewart-Brown, S. (2006) What is the Evidence on School Health Promotion in Improving Health or Preventing Disease and, Specifically, What is the Effectiveness of the Health Promoting Schools Approach? Health Evidence Network Report. Copenhagen: WHO Regional Office for Europe.  Tremblay, M. and Richard, L. (2011) Complexity: A potential paradigm for a health promotion discipline. Health Promotion International, doi: 10.1093/heapro/dar054  Wenzel, E. (1997) A comment on settings in health promotion. Internet Journal of Health Promotion. Available at: – accessed 02 November 2010.  Whitelaw, S., Baxendale, A., Bryce, C., Machardy, L., Young, I. and Witney, E. (2001) Settings based health promotion: a review. Health Promotion International, 16: 339-353.  World Health Organization (1986) Ottawa Charter for Health Promotion. Geneva: WHO.