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

[email protected]

www.uclan.ac.uk/hsu

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Dooris

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

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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

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Sources: St Leger, 2003; Maller et al, 2006; FPH, 2010



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―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

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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


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―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

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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:

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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

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Useful sources: Tremblay and Richard, 2011; Butland, et al, 2007

Healthy Settings: Conceptual Framework

Ecological model of health

Systems perspective

Whole system change

Values

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Sources: Dooris, 2005, Dooris et al, 2007

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Healthy Settings: Whole System Model

Cre

ate

hea

lth

y an

d s

ust

ain

able

wo

rkin

g,

lear

nin

g a

nd

livi

ng

en

viro

nm

ents

Integ

rate health

into

rou

tine life an

d co

re

bu

siness o

f the settin

g

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

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www.unep.org/pdf/unep-geas_oct_2012.pdf

http://www.unep.org/wed

Connect Practice, Theory & Research

Acknow

ledgem

ent: H

ealthy

Schools

Connect Within Settings

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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



Connect Outwards

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Source: adapted from Grossman and Scala, 1993

Schools Hospitals

Prisons

Workplaces

Communities

Sports Stadia

Illness

Health

Connect Outwards

Health & Social

Care Services

Criminal Justice

Systems

Economy

Local & Virtual

Communities

Sport & Leisure

Illness

Health

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: H

ealthy

Schools

Connect Beyond Health

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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

http://www.youtube.com/watch?v=nIdebt9a_iI

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.

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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: S

kyR

ide


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

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5. Root practice in place – recognise

distinctive cultures, structures & histories

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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

Education

health promotion

world health

social justice

settings approach

health promotion

public health

settings approach

21st century