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A comment on settings in health promotion

Eberhard Wenzel
Griffith University
Faculty of Environmental Sciences
Nathan, Qld 4111
Australia

Introduction

Health education addresses humans as individuals and groups. Health promotion intends to address humans as individuals and groups in the settings, in which they live, work, love and play. With the advent of the latest concept of health promotion, i.e. the Ottawa Charter, public health professionals shifted their language from an educational tone to a "community development" tone. They emphasised the importance of living conditions in relation to behaviour, thereby implying that one has to work with the people in contexts in which they are enabled to lead "healthy lives".

Health promotion recognises the idea that people live in social, cultural, political, economic, and environmental contexts. This acknowledgment may have been new for public health, however, sociologists and social psychologists have been aware of the embeddedness of behaviour into larger contexts for a longer period of time. However, the acknowledgment by public health practitioners that health is developed in the context of everyday-life and which itself is structured by its related social system, has not led to a fundamental reconsideration of the social science basis of public health concepts and its incorporation into planning and activity.

Individuals are still expected primarily to change their behaviour despite the relevance that the public health discourse allocates to the socio-structural and cultural conditions of human life. Are we witness of newspeak regarding public health and health promotion?

Settings?

An important term in WHO’s documents on health promotion is setting, by which is indicated that health promotion intends to aim at where people live and work. It is a term which meanwhile structures the Regional Targets of the WHO-Regional Office for Europe, at least as far as health promotion is concerned. It seems relevant to look into the meaning of the setting-concept since it is used to place distance between health promotion from individually oriented approaches which are linked to health education and prevention.

Health promotion is supposed to refer to two different levels of social change:

• improvement of lifestyles and work styles conducive to health,

• improvement of living conditions and working conditions conducive to health.

Since the Ottawa Charter, the concept of health promotion has been used to mainly change behavioural components of health: prevention of smoking, promotion of physical exercise, etc. In addition, broader issues have been put into the forefront by programs such as healthy cities, health promoting schools, health promoting hospitals, health promoting workplaces. These programs refer to what is called in health promotion language settings, i.e. organisational and, in the case of cities, even geographical structures which are interpreted as the context for communication and interaction between individuals and professionals.

The term setting is not introduced as a fundamental or strategic characteristic of health promotion but rather as a tactical label representing the direction of measures to be taken by health professionals to improve the health status of selected population groups. Leo Baric (1) defines settings in a monograph, which is introduced by a foreword of a staff member of the WHO Regional Office for Europe and therefore can be assumed to be an accepted conceptualisation, as follows:

The setting, as a system, can be considered to have an "input" (clients), a production process (care and treatment) and an output (health gain of clients). The main variable in this equation is the difference in clients according to their readiness and competence related to coping and the management of their health problems (input), resulting in a difference in the health gain (output) provided the process is standardised and optimised (i.e. the best available).

This attempt to conceptualise settings is a mechanistic one because it draws heavily on simple models of cybernetics referring to social processes as being "input-output-related". Social interaction between humans does not follow this simplistic concept. Baric’s definition also refers to a medical understanding of disease (rather than a comprehensive understanding of health as physical, mental and social well-being) as it defines the processes that take place in settings as "care and treatment". In subsequent parts of Baric’s argument, settings are considered to be areas of action which health professionals "manipulate" to achieve their goals (2). Settings, according to Baric, are defined frames of reference for any type of intervention as regards health promotion/health education. People are seen as objects of intervention programs, they are targeted to persuade them of behaviour changes, and they are defined as bearers of statistical data rather than as individuals and collectives with specific traditions, biographies, needs, experiences, and patterns of behaviour having been developed over the course of time.

The label setting in health promotion policy papers actually refers to organisational units and even geographical sites now becoming target areas of health promotion. These areas and units have no specific boundaries, nor do they share common characteristics: setting simply stands for another term which is much more honest for the type of health promotion strategies outlined by Baric, namely target area and/or target audience.

Behind this conceptualisation of setting lies nothing of different substance than we already know from traditional health education. The war against individual and collective health-hazardous behaviours does not seem to be over, blaming the victim still seems to be the flavour of the month; it has only changed its name, not its strategies, however the surveillance and monitoring tactics and methods introduced seem to be much more sophisticated than before. In the latter respect, it makes use of all devices and technologies helping to track down individuals and their assumed health-hazardous behaviour and to persuade them to adopt "healthy lifestyles" until they are willing to join the club of the healthy voluntarily. Insurance companies and private and public employers make use of these tactics and methods and go as far as genetic screening of job applicants as a selection method to reduce health care costs. It does not require much creativity to imagine to which kind of society such tactics may lead in the future. Health, as Prof. Lowell Levin (3) of Yale University once stated in a WHO document, may become the ultimate disease when it gets confused with social control.

Settings!

In contrast to Leo Baric settings may be defined as spatial, temporal and cultural domains of face-to-face interaction in everyday-life. As far as health promotion is concerned, these domains seem to be crucial for the development of lifestyles and living conditions conducive to health. At least this is my interpretation of the term setting when analysing policy papers of health promotion such as the Ottawa Charter (4), A call for action (5), and the final report of the Sundsvall Conference on Health Promotion (6).

Historically, the concept of settings played a major role in the development of ecological psychology. In this context they are defined as follows:

A behaviour setting is a place where most of the inhabitants can satisfy a number of personal motives, where they can achieve multiple satisfactions. In other words, a behaviour setting contains opportunities (7).

Rudolf Moos, who plays a prominent role in the development and application of the setting-concept summarises its characteristics as follows:

1. behaviour settings have one or more standing patterns of behaviour. These patterns of behaviour are not the behaviour of individuals, but of people en masse.

2. behaviour settings (...) involve not just behaviour but also a milieu that is physical and may include man-made objects such as buildings, streets, or chairs.

3. the physical milieu surrounds or encloses the behaviour.

4. the standing patterns of behaviour in the setting are similar in structure to the milieu. That is, the physical and temporal aspects of the setting, and the standing patterns of behaviour in the setting are interdependent (8).

According to this conceptualisation, it is clear that behaviour settings refer to two levels of action: patterns of action and their context. Patterns of action means that only certain actions, respectively behaviours are permitted within the given context. Barker (9) exemplifies the behaviour setting concept in relation to the design of supermarkets in which people are led to use specific paths from the entrance to the cashier. These paths are designed according to socio-psychological analyses of peoples' assumed preferences regarding shopping and the preferences of the shop-owners regarding selling products. Ultimately, the behaviour setting supermarket is designed to lead people to buy more than they actually wanted to buy and to buy products which they perhaps did not want to buy in the first place.

I conceptualise health-related behaviour as one outcome of the interplay between individuals, their social reference groups and their specific living and working conditions. Urie Bronfenbrenner has coined the term ecology of human development indicating that individual and collective development take place in different social settings all of which are interconnected. The term setting is defined by him as "a place where people can readily engage in face-to-face interaction - home, day care Centre, playground, and so on" (10).

Bronfenbrenner reviews sociological concepts of human development and concludes that they lack an understanding of the complexity of this development because of neglecting the frame of reference in which development takes place:

What we find in practice ... is a marked asymmetry, a hypertrophy of theory and research focusing on the properties of the person and only the most rudimentary conception and characterisation of the environment in which the person is found (11).

In six definitions, Bronfenbrenner outlines the basic ideas of his sociological approach to human development. Of particular interest for health promotion are the four different levels of the social system being of relevance to human development.

The ecology of human development involves the scientific study of the progressive, mutual accommodation between an active growing human being and the changing properties of the immediate settings in which the developing person lives, as this process is affected by relations between these settings, and by the larger contexts in which the settings are embedded (12).

Human development, according to Bronfenbrenner, takes place in relation to four different layers of the social system, i.e. the micro-system, the meso-system, the exo-system and finally, the macro-system. He conceptualises these layers as being interconnected on the one hand and as providing separate opportunities of social interaction being essential for human development. He configures human development to take place in specific socially, culturally, politically and economically defined environments that may be changing in the course of the developmental process. Change may occur within a given environment as well as with regard to movements from one environment to another (e.g., migration, social mobility, status change, etc.). The individual is recognised as a social human being connected to (significant) others and being able to shape her/his future according to her/his plans and, sometimes, despite hampering social and economic conditions. Influence on the developmental process is realised by the individual her-/himself, by her/his significant others, by agencies in relation to the specific environment and by changes of the environment itself.

The ecological environment is conceived topologically as a nested arrangement of concentric structures ... A micro-system is a pattern of activities, roles, and interpersonal relations experienced by the developing person in a given setting with particular physical and material characteristics (13).

The micro-system refers to the actual setting in which the individual interacts with others at a given period of time. This may be the family, kindergarten, school, neighbourhood, workplace, playing-field, street, park, etc. The key characteristic lies in the face-to-face qualities of interaction which the micro-system provides.

On the next layer of the social system, additional features of social interaction are introduced which may go beyond face-to-face interaction.

A meso-system comprises the interrelations among two or more settings in which the developing person actively participates (such as, for a child, the relations among home, school, and neighbourhood peer group; for an adult, among family, work, and social life) (14).

The meso-system refers to the numbers of settings in which a person is interacting with others. Most of the time, people are active in different arenas: as a child, for example, one acts in the family, at kindergarten or school, in the neighbourhood, in the street, etc. As such, the developmental process is not just a matter of the family, but is influenced (more or less strongly) by other micro-systems which the child becomes a part of.

Up till now Bronfenbrenner’s conceptualisation incorporated face-to-face interaction. The next layer of the social system Bronfenbrenner targets, is comprised of arenas of social power which exist despite or because of communal face-to-face interaction. His definition of the exo-system refers to structural relations of power.

An exo-system refers to one or more settings that do not involve the developing person as an active participant, but in which events occur that affect, or are affected by, what happens in the setting containing the developing person (15).

The exo-system refers to the structure of micro-systems, insofar as this structure is defined by other social sectors in one way or another. The interactions of a child in school are not a subject of her/his own will and capabilities and are not only defined by her/his significant others but also by the school environment which is in turn defined by the educational system: curricula, teachers, teacher-student-relations, school building, school administration, etc. influence the interactions of the child to a large extent.

The exo-system of Bronfenbrenner’s analysis refers to the level of influence and power exercised by identifiable communities. They may be able to consider and reflect their own ways of life. However, they may also be dependent on what the next layer of the social system provides, which includes ideological and spiritual determination:

A macro-system refers to consistencies, in the form and content of lower-order systems (micro-, meso- and exo-) that exist, or could exist, at the level of the subculture or the culture as a whole, along with any belief systems or ideology underlying such consistencies ...

The system’s blueprints differ for various socioeconomic, ethnic, religious, and other subcultural groups, reflecting contrasting belief systems and lifestyles, which in turn help to perpetuate the ecological environments specific to each group (16).

The macro-system, finally refers to the policy and polity level of social sectors and society at large. For example, values, beliefs, tradition, political objectives, but also economy, culture, and constitution form the frame of reference of a society which defines to some extent structure and functions of micro-, meso- and exo-system.

As a result of this conceptualisation, Bronfenbrenner provides a new perspective on human development:

Human development is the process through which the growing person acquires a more extended differentiated, and valid conception of the ecological environment, and becomes motivated and able to engage in activities that reveal the properties of, sustain, or restructure that environment at levels of similar or greater complexity in form and content (17).

Social interaction takes place in social situations which are defined and interpreted by the individuals involved. However, their interpretation is already shaped by the knowledge of the situation. For example, before we enter a church, we know what kind of interactions are permitted. The church building already as a complex architecturally, socially and culturally developed symbolic structure represents a frame which is of relevance to social interaction for those who enter the church, and it is of course of relevance for those who just see the church. The concept church indicates not only a culturally defined frame of reference as regards social interaction but also as regards meaning. In this respect, it represents a setting because it indicates for all participants how they are supposed to communicate and interact in this particular frame.

Two aspects are of importance here. A setting refers to:

• a socially and culturally defined geographical and physical area of factual social interaction, and

• a socially and culturally defined set of patterns of interaction to be performed while in the setting.

A setting represents a frame of face-to-face, social interaction among human beings, the meaning of which is socially and culturally shared within the particular group of people being a part of the setting for a certain period of time. That is, this particular meaning of the setting may vary among different social groups at different points in time, it may even be non-existent for other social groups at the same time.

If one talks about settings, one is talking about socially and culturally defined places of interaction which gain their meaning only with regard to those who subscribe to that definition and who interact in these settings. Others may be able to understand the meanings of these settings, but they may also prefer not to become an active part in keeping the setting alive. Setting is a concept referring to interaction that takes place.

Settings and health promotion

Referring to settings does not necessarily mean that health promotion avoids the individual approach of health education which it criticises. There is a constant misunderstanding by several representatives of health promotion inasmuch as they take a structural concept for the solution for their strategic problems (18). When Gregory Bateson (19) referred to patterns that connect, he simply indicated that evolution and subsequently human development is not a matter of individual paths of development but that all development is connected to each other and can be described in certain patterns which impregnate this development and which at the same time are expressions of the evolutionary process. While referring correctly to the recognition of Bateson’s systems theory of evolution at least in some way, the strategic proposals of health promotion which have been drawn from it are misleading:

The challenge is to offer incentives and support for the creation of settings where physical characteristics and social processes interact to enhance healthy living. Housing and neighbourhood can be designed to strengthen the supporting and caring functions of families and friends. Schools and recreation areas can encourage social experiences that shape and maintain healthy behaviour among children. Workplaces can be safe and offer opportunities to be productive in an environment that encourages healthy lifestyles (20).

In this formulation, development and settings emerge as signposts for political measures - they are planned and negotiated, but by whom are these activities carried out and who has control over these measures in terms of public health policies in particular and as regards economic, environmental and other policies in general? The quotation indicates that action should be taken regarding certain domains of everyday life which are seen as being devisable like any other product. It takes living conditions and domains of social interaction as objects of planning and designed changed, thereby neglecting to recognise that these conditions and domains have been developed according to specific historical, economical, political, cultural, and perhaps spiritual frames of reference and will continue to do so. It does not refer to the participation or even co-determination of the people regarding their specific lifestyles and living conditions which determine their use of settings. In other words, it does not connect context (i.e. settings) with patterns (i.e. lifestyles), let alone that it does not connect patterns at all.

This is a mechanistic interpretation of Bateson’s theory which does not take account of the fact that the development of "safe workplaces" or "socially supporting neighbourhoods" cannot be designed by professionals and cannot be negotiated by political institutions displaced from everyday-life of the people they claim to take care of. On a different level of argumentation, it is a misunderstanding of the role of WHO when it claims to be able to improve individual and collective patterns of behaviour in its member states.

It rather should draw its attention to the antagonisms of governmental policies as regards education, economy, health, social welfare and national development and it should feed back to its member states what it believes according to its knowledge goes wrong in their respective territories as regards the development of living conditions and lifestyles and their impact on health of their respected populations.

Conclusion

In public health and subsequently health promotion we have to be careful to define what we want to achieve with whom, when and where. Our activities are oriented to individual and collective well-being as outlined by WHO’s definition of health. If we take the wording of physical, mental, and social well-being seriously, we have to come up with concepts related to where people interact face-to-face on a daily basis, and how we would be able to change either those structural conditions and/or their behaviour.

Settings are a good strategic approach of realising that human behaviour is predetermined by physical and social features and is shaped by cultural traditions (21). However, what is left for us to do, is to define, describe, analyse, and improve those settings we consider to be of importance to public health and health promotion as far as individual and collective social action regarding health is concerned. Despite the lip-service paid to settings, we have not yet been able to come up with realistic descriptions of settings, which we believe to be crucial to the development of living conditions and lifestyles conducive to health.

References

(1) Baric, L. Health promotion and health education in practice. Module 2: The organisational model. Hale Barns, Barns Publications, 1994: 250

(2) op cit., pp. 257-262

(3) Levin LS. Health - the ultimate disease. In: World Health Organisation, Regional Office for Europe (ed.), Health Promotion: Concepts and principle. Copenhagen, WHO-EURO, ICP/HSR 602, 1984: 18-19

(4) World Health Organisation Ottawa-Charter. Geneva, WHO, 1986

(5) World Health Organisation A call for action. Geneva, WHO, 1990

(6) World Health Organisation Sundsvall Handbook. Geneva, WHO, 1993

(7) Barker RG. Ecological psychology. Concepts and methods for studying the environment of human behavior. Stanford, CA, University of California Press, 1968: 219-220

(8) Moos RH. The human context. Environmental determinants of behavior. New York Wiley, 1976: 215-216

(9) op.cit.

(10) Bronfenbrenner U. The ecology of human development. Experiments by nature and design. Cambridge, Mass., Harvard University Press, 1979: 22

(11) op.cit., p. 16

(12) op.cit., p. 21

(13) op.cit., p. 22

(14) op.cit., p. 25

(15) op.cit., p. 25

(16) op.cit., p. 26

(17) op.cit., p. 27

(18) Kickbusch I. Good planets are hard to find. Copenhagen, WHO-EURO, 1990

(19) Bateson G. Mind and nature. A necessary unit. New York, Bantam Books, 1988

(20) World Health Organisation, Regional Office for Europe Health for all targets. The health policy for Europe. Updated edition September 1991. Copenhagen (WHO-EURO), 1993: 67

(21) A first step towards the integration of human development, settings and health promotion is presented by the WHO Regional Office for the Western Pacific in its policy paper New Horizons in health. Manila, 1995.

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