Mark Dooris NHPRC 2013

Place, People, Planet:
The Settings Approach to Health
Promotion: Lessons Learned and
Perspectives for the Future
17 June 2013
Mark Dooris
mtdooris@uclan.ac.uk
www.uclan.ac.uk/hsu
©MarkDooris

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

http://office.microsoft.com
Health and Social Justice:
Health Inequalities – World
Life Expectancy at Birth
http://www.statsilk.com/maps/life-expectancy-interactive-world-map

Sustainability
Environment
Society
Economy

―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.‖
www.metoffice.gov.uk/research/news/alex-otto-article
Sources: Cook et al, 2013, Otto et al, 2013

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

©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

―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

From…Settings as Dimension of Health
Promotion Matrix
To…The Settings Approach
& Healthy Settings

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

©MarkDooris

―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

 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

 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?

Healthy Settings: Complexity
©MarkDooris
Useful sources: Tremblay and Richard, 2011; Butland, et al, 2007

Healthy Settings: Conceptual Framework
Ecological model of health
Systems perspective
Whole system change
Values
©MarkDooris
Sources: Dooris, 2005, Dooris et al, 2007
©MarkDooris

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

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

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]

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

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.

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

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
www.unep.org/wed
Net_Eleck/flickrr
www.unep.org/pdf/unep-geas_oct_2012.pdf

Connect Practice, Theory & Research
Acknowledgement:HealthySchools

Connect Within Settings
©MarkDooris

pupils
teachers
caterers
wider
community
families
governors
Mapping Settings
Connecting Between People
Source: adapted from Dooris, 2005
Ackn: Healthy Schools

travel
mental
health
physical
activity
advertising &
sponsorship
climate
change
food/diet
Mapping Settings
Connecting Between Issues

formal
curriculum
buildings &
grounds
transport
infrastructure
governance
structures
inter-personal
relationships
Mapping Settings
Connecting Between Components
procurement
system

Source: adapted from Grossman and Scala, 1993
Schools Hospitals
Prisons
Workplaces
Communities
Sports Stadia
IllnessHealth 



Connect Outwards

Health & Social
Care Services
Criminal Justice
Systems
Economy
Local & Virtual
Communities
Sport & Leisure
IllnessHealth 



Education
Kindergarten : School
Education
College : University
Connect Outwards

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

Connect Upwards
Ackn:HealthySchools

Connect Beyond Health

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

Causes and manifestations of unsustainable development
and poor health are interrelated, pose interconnected
challenges & offer potential for ‗win-win‘ synergistic solutions.

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

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

Human Health and Ecosystem Health:
Climate Change

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

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

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

Greening Settings: Reflections
―Something we...need to be a lot better at is avoiding
‗multiple silo‘ programmes...‖
Professor Trevor Hancock, Personal Communication – Doctoral Research

Connecting Health and Sustainability:
Cities
www.healthycities.org.uk

Cities

Universities
www.healthyuniversities.ac.uk

Universities
Ackn:SkyRide

Universities

Prisons and Criminal Justice

Prisons and Criminal Justice
―You put the seed in the ground, it
germinates...you‘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

5. Root practice in place – recognise
distinctive cultures, structures & histories

7. Engage with & learn from
social movements

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 http://iopscience.iop.org/1748-9326/8/2/024024/article
 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.

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:
http://rhpeo.net/ijhp-articles/1997/1/index.htm – 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.

Mark Dooris NHPRC 2013

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Mark Dooris NHPRC 2013