We all spend time in a range of different places and it’s clear that they have important influences on our wellbeing. Settings such as schools and workplaces have long been used by health professionals as convenient vehicles for targeting interventions. Understood in this way, settings – together with population groups and health topics or problems – make up the traditional three-dimensional matrix used to organise health promotion programmes, particularly those concerned with encouraging individual behaviour change. However, what’s become known as the settings or settings-based approach moves beyond this fairly mechanistic view, appreciating that the contexts or places in which people live their lives are themselves crucially important in determining health.

The settings approach has developed over more than 30 years to become a key element of health promotion strategy at local, national and international levels. It has its roots within WHO’s Health for All strategy and, more specifically, the Ottawa Charter for Health Promotion, which contended that: “health is created and lived by people within the settings of their everyday life; where they learn, work, play and love…Health is created by...ensuring that the society one lives in creates conditions that allow the attainment of health by all its members.” Kickbusch (1996) has commented that the ‘settings approach’ became during the 1990s the starting point for WHO’s lead health promotion programmes, which involved a shift of focus from the deficit model of disease to the health potentials inherent in the social and institutional settings of everyday life.

According to the WHO Health Promotion Glossary, a Setting for Health is “A place or social context in which people engage in daily activities in which environmental, organizational, and personal factors interact to affect their health and wellbeing.” Examples of settings with established initiatives and programmes include schools, universities, hospitals, prisons, sports clubs, sports stadia and cities. There are also what can be seen as emergent settings, for example digital and virtual communities.

Why use the approach? Health is largely determined by social, economic, environmental, organisational and cultural circumstances – which directly impact wellbeing and also have indirect influences through providing more or less supportive contexts within which people make lifestyle choices. Health promotion therefore requires investment in the places in which people live their lives. More specifically, the approach recognises that people’s lives are complex and that the processes of enabling human flourishing and of addressing 21st century health challenges are equally complex. Complexity requires us to embrace holism and emergence, appreciating that the patterns and system-related behaviours relating to these challenges are not predictable, are not linear and cannot be understood through reductionist analysis. This means that the underlying influencing factors and conditions are interrelated and can be most effectively tackled not by ‘single thread’ interventions, but through comprehensive, integrated programmes in the settings of everyday life – where people learn, work, play, love, live and die.

Conceptually, Dooris (2014) has argued that the settings approach is rooted in health promotion values such as equity, partnership, participation and empowerment – and has core overarching characteristics.

  • First, it acknowledges the reality of illness and disease, but goes beyond prevention to embrace ‘salutogenesis’, concerned with what creates and sustains wellbeing and makes people thrive and flourish in in particular contexts and places.

  • Second, it adopts an ecological model. It appreciates that health is determined by a complex interaction of factors operating at different levels; it focuses on the interrelationships between people and place; and it addresses human health within the framework of ecosystem health.

  • Third, it views settings as systems, acknowledging interconnectedness, interdependency and synergy between different components, whilst recognising that each setting is connected to the world around it.

  • Fourth, it adopts an holistic change focus, moving beyond disconnected ad-hoc approaches and instead seeking to embed health by using multiple interconnected interventions.

  • And fifth, it appreciates that most settings do not have health as their main mission or raîson d’être – and it is therefore essential to advocate for health in terms of impact on or outflow from ‘core business’.

Building on this conceptual framework, it can be seen that, following Baric (1993), the settings approach involves understanding and harnessing the multi-dimensional nature of settings – and, within this, the relationship between place and people, between the structural dimension provided by their contexts, facilities, services and programmes, and the human agency within them. By doing this, we are better placed to take a comprehensive approach, as argued by Dooris, Farrier et al (2018):

  • creating healthy, supportive and sustainable environments

  • integrating health into the routine life and core business of settings (whether this is quality of patient care in hospitals; education in universities; or rehabilitation in prisons)

  • contributing to the wellbeing and sustainability of the wider community.

As highlighted by Whitelaw et al (2001), it is, though, important to recognise that the approach is implemented in different ways, due to both divergent interpretations and a pragmatic response to what is possible within particular constraints.

As well as highlighting the challenges to generating evidence of effectiveness for the settings approach, Dooris (2006) has highlighted the confusion between the concept of ‘doing health promotion in the setting’ (largely programmes aimed at modifying individual behaviours within a setting) as opposed to ‘health promoting settings’ (involving multiple interconnected interventions aimed at modifying the conditions of the setting or even the factors or conditions underlying the setting). Poland et al (2009) have addressed this by providing a framework for planning and delivering multiple interventions in settings that are aimed at the whole setting or underlying conditions.

Dooris (2013) has also argued for a joined-up and holistic approach that uses advocacy to connect upwards and address wider determinants of health, whilst proactively connecting within and between settings. Bloch (2014) and Kokko et al (2013) have further explored the importance of connecting between different settings to maximise impact and effectiveness.

The importance of forging links between health and agendas such as equity and sustainability has been emphasised by a number of writers, including Poland and Dooris (2010), Orme and Dooris (2010), Bentley (2007), Davis and Cooke (2007), Baybutt, Dooris and Farrier (2018) and Rice and Hancock (2016). This imperative is further reinforced by the Sustainable Development Goals and 2030 Agenda for Sustainable Development, as made clear by WHO's Shanghai Declaration on Promoting Health within the 2030 Agenda for Sustainable Development (2016), which reaffirmed the importance of the approach, arguing that  "Health is created in the settings of everyday life - in the neighbourhoods and communities where people live, love, work, shop and play."