Health Promotion Settings

Principles and Practice

Angela Scriven, Margaret Hodgins, Angela Scriven, Margaret Hodgins

• Publisher: SAGE Publications Ltd
• Year: 2011
• ISBN:
  9781446291474
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Health Promotion Settings combines the theoretical discourse of the settings approach, covering a wide range of fundamental principles, concepts and policy issues, with real life examples of settings, including workplaces, schools, neighbourhood, cities and prisons. Frameworks and processes that are actively shaping health promotion in settings in the 21st Century are documented and the ideas and research covered will provide a vital set of indicators for those who promote health in settings. Combining theory with practical examples and case studies, the authors show how a settings approach can work in practice, drawing on a range of local, national and international initiatives and coordinated projects.

Health Promotion Settings provides a rich source of ideas and case examples which highlight the challenges for promoting health in a range of contexts. Special attention is given to the workplace as both a priority area for health promotion and a key determinant of health.

Written by a highly experienced team of health promotion and public health professionals, academics and researchers, this book is essential reading for both students and practitioners working towards the improvement of health using a settings approach.

Online Resources are provided.

1

Health Promotion Settings: An Overview

Angela Scriven

Aims

• To provide an overview of the content of the book, outlining the context and structure
• To offer the rationale for a text on the settings approach to health promotion
• To identify the focus of each of the chapters in the book
• To introduce general themes and arguments that will be expanded on in the specific introductions to Parts I – III

Since the Ottawa Charter (WHO, 1986) highlighted the idea that health is created within the settings of people’s everyday lives, where they learn, work, play and love, the settings approach has become an established component of the global health promotion agenda for action. The World Health Organization (WHO, 1998) has defined settings as the context in which people engage in daily activities and in which environmental, organizational and personal factors interact to affect health and wellbeing. The WHO definition also argues that normally, settings can be identified as having physical boundaries, a range of people with defined roles, and an organizational structure. Making these contexts the object of health promotion intervention and inquiry uses a wide range of processes and takes many different forms (Poland et al., 2009), but frequently involves some form of organizational development, including change to the physical environment and to the organizational structure (see Whitelaw et al., 2001 for a critical overview).

Settings can include those that have been coordinated at an international level by WHO, such as Healthy Cities, Villages, Municipalities and Healthy Islands projects, the networks of Health Promoting Schools and Health Promoting Hospitals, and the Healthy Marketplaces and Health Promoting Workplaces projects (Kickbusch, 1998). There are those that argue that twenty-first century settings should also include other more diffuse contexts, such as where people Google, shop and travel (Kickbusch, 2006). Currently healthy setting approaches have been implemented in many different ways in multiple areas. A list of all existing WHO coordinated Healthy Settings projects, including initiatives and documented activities, can be found on the WHO web pages at www.who.int/healthy_settings/types/
en/index.html. The list cites:

• Cities
• Villages
• Municipalities and Communities
• Schools
• Workplaces
• Markets
• Homes
• Islands
• Hospitals
• Prisons
• Universities
• Ageing

Each setting on the list above has a web link which provides a description of the approach, outlines the fundamental theory of the programme and provides information on implementation, existing networks and available resources for each application. The website, therefore, is an invaluable resource for those working in settings.

The important point to note, however, is that planned, comprehensive and multisectoral settings approaches to health promotion action are now well established and an essential component of the twenty-first century health promotion agenda (Dooris, 2009), with the settings approach delivered locally and in many cases coordinated nationally and internationally by organizations such as WHO. The overall purpose of this book is to provide a detailed account of the principles on which a settings approach is based and to highlight some of the settings listed above. The book will combine a theoretical discourse of the settings approach with real-life examples of the settings, covering a wide range and including workplaces, schools, neighbourhoods, cities and prisons. Thinking, frameworks and processes that are actively shaping health promotion in settings in the twenty-first century are documented and the ideas and research covered will provide a vital set of materials for those who promote health in settings. The examination of health promotion through a settings approach is covered in three discrete parts, as outlined in Box 1.1.

Box 1.1 Health Promotion Settings in three parts

The book is divided in to three distinctive parts. Each part has not only a discrete focus but also a synergistic relationship.

Part I concentrates on theoretical principles, policy and the practical processes underpinning the settings approach to health promotion. The focus of the contributors will be on the history, concepts, values, principles, planning and evaluation that are fundamental elements to health promotion action in settings, covering, for example, partnership working.

Part II will offer examples of the broad range of settings, including schools, neighbourhoods, cities, prisons.

Part III provides an in-depth examination of workplace settings and will act as a major case study of a settings approach. A critical overview of the workplace context is offered alongside evidence and examples of practice covering a range of workplaces, including manufacturing and small and medium-sized enterprises (SMEs).

Each part of the book has an introduction which summarizes the key themes. There is cross-referencing between the three parts in order to locate theoretical, conceptual, process and policy issues within each setting.

There are a number of reasons for devoting a whole section to the workplace setting. Firstly, it is important to understand both the breadth and depth of the settings approach to health promotion. The workplace is a substantial setting and has been identified as one of the priority areas for health promotion into the twenty-first century (WHO, 2010). The significance of the workplace in terms of influencing the determinants of health is an important motive for the WHO prioritizing this setting. The nature of employment is a major contributing factor to health, directly influencing the physical, psychosocial and economic wellbeing of the population. Changing the overall conditions of work is recommended in terms of global action on the social determinants of health (WHO, 2008) and preventing accidents and illness at work can result in significant population health gain. The International Labour Organization (ILO) estimates that within the world’s 2.7 billion workers, at least 2 million deaths have occupational causes (Rosenstock et al., 2006). The relationship between adverse working conditions and negative health outcomes displays a strong social class gradient, with higher risk for accident and illness clustering in low status occupations (WHO, 2008), suggesting that improving working conditions might contribute significantly to reducing health inequities. Further, settings-based workplace health promotion has the potential not just to protect but to improve health through creating positive and health enhancing social environments and work cultures. The global labour force participation rate is 65% (ILO, 2008), demonstrating the extensive reach of the workplace setting and making it an ideal setting and infrastructure to support the promotion of health to large audiences. Using the modes of communication already in place in a workplace can be an effective means of encouraging participation in programmes and follow up with employees (Naidoo and Wills, 2009). Moreover, the workplace gives access to target groups not easily reached in other ways, for example, younger men. Finally, the reach of the workplace as a setting can also extend beyond employees, having indirect influences on families and communities, such as work–life balance policy and practice.

The workplace can be considered an overarching setting insofar as other well-established settings – schools, universities, prisons and hospitals – are also workplaces. To take just one illustration of this, the health sector is a major employer, estimated to employ 1.3 million people in the UK alone. Links need to be made, therefore, between hospitals, schools, prisons and university settings in Part II, which are workplaces, and the more specific examples of workplace settings in Part III. See Figure 1.1 for a figurative explanation of how the settings discussed in this book relate and Chapter 2 for a discussion of the link between the different health promoting settings.

Figure 1.1 Connections between different health promotion settings

Because the settings approach is universal and many of the settings, such as health promoting schools, are linked to global initiatives, all of the issues and ideas addressed in this book will have international applicability, with international examples and comparisons used where applicable or appropriate.

Box 1.2 Health Promotion Settings offers:

• Reference to relevant and recent settings interventions, research, policies and evidence informed practice.
• Ideas, debates, issues linked, where appropriate, to international examples and global policies.
• Identification of principles, contemporary trends and viewpoints on developing health promotion initiatives in settings.

Part I opens with a chapter containing a detailed analysis of the origins, history, evolution and challenges of health promoting settings. The review of the theoretical and conceptual base, including outlining frameworks and typologies, of the settings approach highlights its ecological perspective, presenting an understanding of settings as dynamic open systems and with a primary focus on whole system organizations, development and change. The benefits of settings as foci of health promotion are debated and questions are asked about the challenges that health promoters face when working in settings. Key challenges are discussed and these include the difficulties relating to the construction of the evidence base, the diversity of conceptual understandings and practice, and the complexity of evaluating whole system approaches. The chapter concludes by exploring key issues: funding evaluation within and across settings; ensuring links between evidence, policy and practice; and clarifying and articulating the theories that underpin the settings approach generically and inform the approach within particular settings.

This broad opening introduction is followed in Chapter 3 by an examination of one of the introductory themes, a whole systems approach to working in settings. Settings are complex dynamic systems, set within and interacting with, larger systems, such as the political or economic environment. This view of settings as systems is consistent with the core principles and theory of health promotion. While it is often the case that problems seen in systems are addressed by isolating and attending to specific elements or parts of the system, for example the teachers in a school, or the canteen in a workplace, systems thinking advocates that change within a system can best be achieved by considering how the parts relate to one another and working with the system as a whole. Further, a healthy settings approach can take an organization beyond problem solving, contributing to a bigger picture of systems development and evolution. These ideas are discussed in this chapter with special reference to successful healthy settings work, the Management Standards Approach to work-related stress and the Bullying Prevention programme for schools. The overview of the Management Standards Approach demonstrates how at an organizational rather than individual level, workplaces need to engage both management and workers in joint problem solving to develop actions to address gaps between organizational practice and evidence informed standards. The Bullying Prevention programme relates to a comprehensive, school-wide programme designed for use in secondary level schools, for pupils aged 11–18 years of age. Its goals are to reduce and prevent bullying problems among school children and to improve peer relations at school. The programme comprises parent, school, classroom and community elements and has been evaluated extensively. Both initiatives are examples of how to draw on a systems approach in settings with a view to improving health.

Partnership working is a fundamental principle and prerequisite to work within settings. Chapter 4 begins by arguing that enabling and encouraging people to participate in the process of defining and promoting their collective needs and concerns in relation to health are key aims in health promotion and fundamentally important to a healthy settings approach. The difference between collaboration, participation and partnerships will be outlined and critiqued, and recommendations made for how professionals working in settings can fully engage in collaborative, participatory and partnership working with individuals, groups and other professionals.

Planning and evaluating health promotion in settings is multifaceted because of their inherent complexity. Chapter 5 examines the principles of health promotion programme planning and evaluation and their application within a settings approach. The assessment of health needs within settings underpins effective planning, and sources of evidence, including lay knowledge, need to inform the design of interventions. A simple planning framework will be utilized to demonstrate how health goals can be met in the context of settings through establishing realistic objectives, choosing appropriate methods and mobilizing professional and community resources within the setting. The chapter also explores how evaluation can be built into projects and interventions, and lead to enhanced learning across settings. Measurement of change at both individual and within the broader parameters of the setting is critically examined with reference to wider methodological debates on the significance of evaluation in health promotion. It is argued that an understanding of the range of health outcomes enables the selection of appropriate indicators and evaluation methods. Issues pertaining to health promotion evaluation, including the merits of wider stakeholder engagement, are explored, with examples drawn from different settings. The chapter concludes by arguing that clear articulation of health goals, attention to processes and strengthening evaluation within the planning cycle are crucial to a settings approach.

Having covered the fundamental principles that guide work in settings, Part II illustrates the settings themselves and begins with a chapter on healthy neighbourhoods and communities. Neighbourhoods and communities are important settings for health promotion because health inequality and social exclusion derive from poor social and physical environments. Multiagency approaches in partnership with communities appear to hold the key to closing the health gap and delivering health improvements. Many influences on health operate at the community and neighbourhood level, among them culture, religion, housing and environment. Working at the community level opens up opportunities for health empowerment and building up the capacity of communities to participate in meeting their health needs. The Healthy Communities Programme is an example of how this can work. The programme aims to build the capacity of local authorities working within their communities to tackle local health inequalities, to provide leadership to promote wellbeing, and to foster a joined up approach to health improvement across local government itself and through Local Strategic Partnerships (LSPs) and Local Area Agreements (LAAs). The chapter critically considers the various approaches taken to advance the community as a setting for health, locating the approach in policy and practice agendas.

Communities and neighbourhoods reside within larger conglomerations. So, the next chapter considers cities as settings through t...