Mark Dooris

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Healthy Settings Developing Theory, Joining Up
Practice, Generating Evidence
Mark Dooris University of Central
Lancashire mtdooris_at_uclan.ac.uk www.healthysettin
gs.org.uk
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Presentation Outline

• background, origins and evolution
• overview of healthy settings theory
• theory into practice
• challenges and opportunities
• conclusion

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• 1. Background, Evolution Policy Context

• The Healthy Settings approach
• Origins and development

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Settings as a Dimension of the
Health Promotion Matrix
Setting
Population Group
Topic / Problem
Methods
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Healthy Settings What?

• The place or social context in which people
  engage in daily activities in which
  environmental, organizational and personal
  factors interact to affect health and wellbeing.
• A setting is also where people actively use and
  shape the environment and thus create or solve
  problems relating to health. Settings can
  normally be identified as having physical
  boundaries, a range of people with defined roles,
  and an organisational structure.
• Source Settings for Health WHO Health
  Promotion Glossary, 1998
• Aim to address that interplay of factors and
  integrate a commitment to health
  within culture, structures and
  routine life of settings

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Healthy Settings
Origins and Development
Health is created and lived by people within the
settings of their everyday life where they
learn, work, play and love.
Health for All 1977-
Ottawa Charter 1986

Healthy Cities Healthy Settings
Jakarta Declaration 1997
New HFA Health 21 1998
Bangkok Charter 2005
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Healthy Settings Why?

• Health determined outside of health services
• Health promotion requires investment in social
  systems in which people live their lives

Illness
Leisure Recreation
Health Social Care
Criminal Justice
Ottawa Charter - strategies - - processes -
Community
Work/ Economy
Education
Health
Source adapted from Grossman and Scala, 1993
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Healthy Settings European/Internatio
nal Timeline
Background Policy Context
Settings-related Initiatives

• Health for All 2000
• Ottawa Charter
• Sundsvall Statement
• Agenda 21
• Jakarta Declaration
• Settings for Health in WHO Glossary
• Health 21 Target 13
• WHO European Investment for Health and
  Development Office
• 2005 Bangkok Charter

• Healthy Cities Project
• Health Promoting Hospitals Project
• Safe Communities
• Health Promoting Schools Network
• Regions for Health Network
• 1994 Declaration on Occupational Health for All
• Health in Prisons Project
• Yanuca Declaration on Healthy Islands
• Health Promoting Universities Book
• Western Pacific Healthy Districts Report
• Western Pacific Healthy Marketplaces Guidance

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• 2. Healthy Settings Overview of Theory

• Ecological model of health promotion
• Systems perspective
• Whole system organisation development/change
  focus

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Ecological Model of Health Promotion

• Health determined by interplay of environmental,
  organisational and personal factors
• Shift of emphasis to salutogenesis health
  creation
• Focus on whole populations
• Holistic perspective develop supportive
  contexts in places people live their lives

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Systems Perspective

• Settings as dynamic complex systems with inputs,
  processes, outputs and impacts
• Interconnectedness, interrelationships,
  interdependencies and integration between
  different elements
• Each setting part of a greater whole an open
  system in synergistic exchange with the wider
  environment, and within this, other settings

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Whole System Organisation Development and Change

• Primary focus on introduction and management of
  change within the whole organisation
• Applying whole system thinking
• Using organisation development and change
  management approaches and techniques

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• 3. Healthy Settings Theory into Practice

• Focusing on three key areas
• Balancing different considerations
• Putting in place an operational process
• Mapping connections and relationships

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Theory into Practice Key Focus Areas

• Creating supportive healthy living and working
  environments

Setting
Developing links with other settings and wider
community
Integrating health into daily activities of the
setting
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How? A Question of Balance
whole system ecological settings approach

• institutional
• agenda core business
• ?
• health
• promotion agenda

organisation development change management
? high visibility innovative projects
top-down political/ managerial commitment
? bottom-up engagement empowerment
Methods e.g. policy development, environmental
modification, social marketing, peer education,
impact assessment
Values e.g. participation, equity, partnership,
sustainability
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How? Mapping Connections
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How? Mapping Connections
Systems thinking is a discipline for seeing
wholes. It is a framework for seeing
interrelationships rather than things, for seeing
patterns of change rather than static
snapshots Source Senge, 1990
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How? Connecting Between People
teachers
pupils
wider community
families
caterers
governors
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How? Connecting Between Components
inter-personal relationships
formal curriculum
transport infrastructure
governance structures
indoor environment
school grounds
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How? Connecting Between Issues
mental health
sexual health
advertising sponsorship
substance use
physical activity
food/diet
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• 4. Healthy Settings Challenges Opportunities

• Developing theory
• Staying with the bigger picture
• Developing the evidence base

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Developing Theory

• Wenzel (1997) use to perpetuate individually
  intervention conflation of health promotion in
  settings with health promoting settings.
• Whitelaw et al (2001) variance in understanding
  and practice difficulties of translating
  philosophy into action typology of settings.
• Green et al (2000) differences within and across
  categories of settings danger of leaving out
  excluded and marginalised groups.

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Staying with the Bigger Picture
HEALTH
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Staying with the Bigger Picture Connecting
Outwards 1
Health issues peoples lives connect a range of
different settings
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Staying with the Bigger Picture Connecting
Outwards 2
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Staying with the Bigger Picture Connecting
Outwards 3
Macrosystem
Exosystem
Norms
Values
FE HE
Mesosystem system of Microsystems
Prison
Parents Workplace
School
Chronosystem
Stadia
Home
Child
Health Services
Laws
Neighbourhood
Beliefs
Societal Culture Sub-Cultures
Healthy Settings portrayed using
Bronfenbrenners
Theory of Human Development/Social Ecology
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Staying with the Bigger Picture Connecting
Outwards 4

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Staying with the Bigger Picture Connecting
Upwards

• use advocacy and mediation skills to encourage
  action to address the underlying determinants of
  health, work upwards to influence institutional
  policy and practice within and beyond settings

• make connections between health, sustainable
  development, regeneration and CSR
• audit impact of institutional policies and
  practices
• use corporate muscle to put pressure on
  governments and other key players to build
  healthy public policy

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Staying with the Bigger Picture Connecting
Beyond Health 1
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Staying with the Bigger Picture Connecting
Beyond Health 2
Risk losing the language of health
liveable
sustainable
vibrant
innovative
creative
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Perceived Benefits
Developing the Evidence Base

• robust conceptual base drawing on organisational
  development, change management and systems theory
• comprehensive framework within which to work
  holistic ownership of health and sustainable
  development
• connections between people, environments and
  behaviours
• interrelationships between different groups of
  people
• interactions between different health issues and
  initiatives
• inward, outward and upward perspective wider
  impact of setting maximising contribution to
  holistic public health

however.
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Developing the Evidence Base The Problem
The settings approach has been legitimated more
through an act of faith than through rigorous
research and evaluation studies. St Leger,
1997
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Developing the Evidence Base The
Challenges 1

• Construction of evidence base and funding for
  evaluation and systematic reviews tends to focus
  on specific behaviours, health topics or diseases
  not on settings
• what settings initiatives achieve does not
  fit easily into an epidemiological framework of
  evidence but needs to be analysed in terms of
  social and political processes.
• Kickbusch, 2003

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Developing the Evidence Base The
Challenges 2
2. Diversity of interpretations and real-life
practice brought together under the healthy
settings banner makes it difficult to generate
a substantive body of research that allows
comparability and transferability
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Developing the Evidence Base The
Challenges 3
3. Complexity of evaluating integrated and
ecological whole system approaches

• Integrated approach means that health becomes a
  part of the core activity of the setting
• Whole system approach focuses on relationships
  and the spaces between not
  just on separate elements
  (within between settings)

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Developing the Evidence Base The
Challenges 4
?

• Resulting ongoing tendency to evaluate only
  discrete projects within settings thus fail
  to demonstrate the added value of the settings
  approach as a whole in terms of synergistic
  effects
• Potential value of theory-based evaluation,
  drawing on experience of use with complex
  initiatives
• Requires us to clarify theory, engage with policy
  makers and secure long-term funding

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Conclusion
global
problems
complexity
solutions
21st century
local
questions
answers
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Conclusion

• Despite an apparent widespread acceptance of a
  socio-ecological model of health amongst people
  working in health promotion, most health
  promotion activity has continued to be issue
  based or else has focussed on only one
  determinant at a time. Rhetoric has largely
  failed to become reality. Thus, much of the
  change that has actually happened has been
  first-order change, involving relatively
  small-scale and minor adjustments, and without
  any major impact on the determinants of health or
  policy development.
• Second-order change, which involves a
  paradigmatic shift leading to new structures,
  processes, actions and outcomes, has barely begun
  to happen. It will not happen until the starting
  point for action is the creation of health, not
  an issue or problem, a disease or death, but
  health itself. Nor can it happen until it is
  accepted that social systems are complex and
  interwoven, and their interconnections are
  crucial to the creation of health.
• Ziglio et al 2000

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Conclusion
prisons
workplaces
universities
colleges
hospitals
communities
schools
stadia
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Healthy Settings Developing Theory, Joining Up
Practice, Generating Evidence
Mark Dooris University of Central
Lancashire mtdooris_at_uclan.ac.uk www.healthysettin
gs.org.uk