Introduction

Health promotion has been carried out in particular settings for many years. Workplaces and schools, for example, have provided established channels to reach defined populations. The concept of a settings approach to health promotion, however, is quite distinct and first emerged in the 1980s. The settings approach seeks to make systemic changes to the whole environment. This contrasts with using the setting as a convenient route to access individuals and provide traditional health education messages. The Ottawa Charter (World Health Organization 1986, p. 3) stated that ‘health is created and lived by people within the settings of their everyday life: where they learn, work, play and love’. One of the five key action areas identified in the Ottawa Charter was creating supportive environments. As we have seen in this book the focus of health promotion activity is moving away from identifying the diseases and conditions contributing to ill health and the groups at risk, to identifying the complex interplay of factors which create health. It is in settings – at school, at work, in our neighbourhood, in hospital or in prison – that we live our lives and it is these contexts or settings which need to be made more conducive to health.

The settings approach builds a concern for health into the fabric of the system and makes sure that the routine activities of the system are committed to and take account of health. Adopting a healthy-settings approach is fundamentally different to carrying out a one-off short-term health promotion project within a particular setting, which is referred to as ‘health education in a setting ’ as opposed to a ‘settings for health ’ approach (Tones & Green 2006). The settings approach is a long-term one.

In most cases it is being implemented through defined projects which are designed to:

The first and best-known example of settings-based health promotion is the Healthy Cities project. Originally this was a small project initiated by the World Health Organization in 1986 to put the Ottawa Charter and Health for All principles (World Health Organization 1985, 1986) into practice. It has subsequently expanded to become a worldwide movement incorporating over 1200 cities in more than 30 countries in the European region (www.euro.who.int/%20healthy-cities). Parallel initiatives have been developed and are coordinated by European Networks in schools, hospitals, workplaces, prisons and universities. The UK health strategies have all referred to the importance of settings. The Health of the Nation, published in 1992, stated that settings ‘offer between them the potential to involve most people in the country ’ (Department of Health 1992). Schools, neighbourhoods, workplaces and prisons are also identified in Choosing Health: Making Healthy Choices Easier (Department of Health 2004) as key settings through which inequalities in health should be tackled.

The settings approach is complex and is characterized by several unique factors (Dooris 2005):

The benefits of such an approach are hard to quantify but appear to be significant. Benefits include encouraging partnership working and collaboration, embedding health in organizational structures and systems and taking account of broader determinants of health. Perhaps not surprisingly, given the complexity of this approach, evaluation and evidence for the effectiveness of the settings approach are rather scanty:

‘The settings approach has been legitimated more through an act of faith than through rigorous research and evaluation studies … much more attention needs to be given to building the evidence and learning from it’ (St Leger 1997, p. 100).

Dooris (2005) proposes the use of theory-based evaluation to build a stronger evidence base for the settings approach.

Part 3 looks at health promotion in five key settings:

Each setting is addressed in a separate chapter but it is important to remember that the settings are not discrete but coexist as part of a wider independent system. Schools, workplaces and hospitals are all in neighbourhoods and there is a constant flow of people within and between the settings. Prisons, although more separated from their neighbourhood, are also sited in a specific locality and impact upon that locality in terms of employment and transport. There are many other settings where health promotion interventions may be delivered e.g. night clubs or barbers ’ shops. Tones & Tilford (2001) have argued that the healthy-settings approach is unlikely to have any long-term impact on population health until ‘different settings have congruent aims and opearate synergistically’.

Each of the following chapters examines why the setting is appropriate for health promotion, identifying the factors of the settings which affect health and outlining some health-promoting initiatives which have been developed in that setting.