available and that one third of the decline occurred before the cause was known. This argument for refocusing on the environmental determinants of health and personal prevention coincided with an emerging emphasis on ecological thinking that moved beyond the mechanistic sanitary approach of the old public health. This new movement for public health found expression in three related WHO initiatives: the 1977 Declaration of Alma-Ata (8) – which described a vision of primary health care integrating public health, population and environmental concerns; the strategy for health for all by the year 2000 (9) – with its emphasis on equity, public participation, intersectoral collaboration and the need to reorient heath systems and services; and the 1986 Ottawa Charter for Health Promotion (10) – with its focus on supportive environments and public policies to support health development. The new and ecological public health has led naturally to a focus on settings as environments or habitats within which people live and work. One of the first practical attempts to operationalize the new way of thinking on a systematic basis came with the WHO Healthy Cities project, the intention of which was to take the health for all strategy off the shelves and into the streets of Europe (11,12). This has been followed and complemented by a developing focus on other settings, as witnessed by the publication of a national health strategy for England (13) that specifically advocated action within homes, schools, cities, workplaces, hospitals, prisons and environments. In some ways this can be seen as a shift from vertical thinking – whereby individual public heath problems remain compartmentalized, to horizontal thinking – whereby links and interactions are made explicit and a synergistic approach is adopted through coordinated action on a range of health determinants. DEVELOPING SETTINGS Although each setting is unique, drawing on the experience of other settings-based work is valuable in developing the concept of the healthpromoting university. The framework developed in the of England for healthy prisons (14) offers one possible model – looking at the setting from the perspective of five parameters:
developing healthpromoting university projects presents a timely opportunity to reflect on their experience, develop methods and apply them to other higher education institutions. REFERENCES Ashton, J. & Seymour, H. The new public health. Milton Keynes, Open University Press, 1988. McKeown, T. The role of medicine: dream, mirage or nemesis? London, Nuffield Provincial Hospitals Trust, 1876. Cochrane, A. Effectiveness and efficiency: random reflections on health services. London, Nuffield Provincial Hospitals Trust, 1972. Morris, J. Uses of epidemiology. Edinburgh, Churchill Livingstone, 1975. Illich, I. Medical nemesis: the expropriation of health. London, Calder & Boyers, 1975. Townsend, P. Inequality and the health service. Lancet, i: 1179– 1190 (1974). Lalonde, M. A new perspective on the health of Canadians. Ottawa, Information Canada, 1974. Alma-Ata 1978. Primary health care. Geneva, World Health Organization, 1978 (“Health For All” Series No. 1). Global strategy for health for all by the year 2000. Geneva, World Health Organization, 1981 (“Health For All” Series, No. 3). Ottawa Charter for Health Promotion (1986). Health promotion international, 1(4): iii–v (1986) and Canadian journal of public health, 77(6): 425–430 (1986). Ashton, J. et al. Healthy Cities – WHO’s new public health initiative. Health promotion international, 1(3): 319–323 (1986). Tsouros, A.D., ed. World Health Organization Healthy Cities project: a project becomes a movement. Review of progress 1987 to 1990. Copenhagen, FADL Publishers and Milan, SOGESS, 1991. Secretary of State for Health. The health of the nation. A strategy for health in England. London, H.M. Stationery Office, 1992.
principles and practice. London, Health Education Authority, 1993, pp. 4–6. Secretary of State for Health. The health of the nation. A strategy for health in England. London, H.M. Stationery Office, 1992. Baric, L. The settings approach – implications for policy and strategy. Journal of the Institute of Health Education, 31(1): 17– 24 (1993). Baric, L. Health promotion and health education in practice. Module 2 – the organisational model. Altrincham, Barns, 1994. Grossman, R. & Scala, K. Health promotion and organizational development: developing settings for health. Vienna, IFF/Health and Organizational Development, 1993 (WHO European Health Promotion Series, No. 2). Dowding, G. Lancaster University Health Promoting University Project: 1st annual report. Lancaster, Morecambe Bay Health Promotion, 1995. Harrison, D. Health promoting hospitals in Europe. In: Riley C. et al., ed. Releasing resources to achieve health gain. London, Routledge, 1995, pp. 114–123. Harrison, D. Population versus individual health gain. In: Proceedings of the International Workshop on Outcome Governed Health Care, 12–13 June 1997. Linköping, Sweden, European Clearing House on Health Outcomes, in press. Pascale, R. Managing on the edge: the learning organization. New York, Simon and Schuster, 1990. Baric, L. Promoting health: new approaches and developments.Journal of the Institute of Health Education, 30(1): 6–16 (1992). Newell, S. The healthy organisation: fairness, ethics and effective management. London, Routledge, 1995, pp. 165–191. Dooris, M. Healthy settings and healthy cities: fragmentation orholism? UK Health for All Network news, summer: 9. Liverpool, HFA Network (UK) Ltd., 1993. Naidoo, J. & Wills, J. Health promotion: foundations for practice. London, Baillière Tindall, 1994, p. 165. Dooris, M. Cited in: Chaplin, J. Health promoting settings. Community health action, 32: 3 (1994).
REFERENCES Ali Khan, S. Greening polytechnics. London, Committee of Directors of Polytechnics, 1990. Department of the Environment. This common inheritance: Britain’s environmental strategy. London, H.M. Stationery Office, 1990. Department of the Environment. Environmental responsibility: an agenda for further and higher education. London, H.M. Stationery Office, 1993. Department of the Environment. Environmental responsibility: a review of the 1993 Toyne report. London, H.M. Stationery Office, 1996. Labonte, R. Community and its health – its power and its problems. Journal of contemporary health, 4 (summer): 2–3 (1996).
Action learning for health on campus: muddling through with a model? University College of St Martin, Lancaster Alan Beattie BACKGROUND: ROOTS AND INSPIRATION The sources of the project at the University College of St Martin lie in part in the challenge of teaching health promotion in universities. Universities in the United Kingdom have three distinct strategies for developing professional preparation for health education and health promotion (1): the new cadres approach, which sets out to create new health education and health promotion specialist practitioners; the mainstreaming strategy, which aims to install effective health education and health promotion practice as a central element in the role of the existing major helping professions; and the alliances approach, which invests in developing patterns of teamwork for health education and health promotion for specific settings (2–4). The work on St Martin’s as a Health Promoting College was undertaken as a sort of practicum on the campus itself to link academic studies of health education and health promotion to practical action at the local level (5,6). Another relevant model was what a 1977 report from the Organisation for Economic Co-operation and Development (7) had called “a regional health university” – committed to developing teaching and research across a range of health professions on public health issues relevant to the local population. Finally, a third and crucial influence was a 1993 book called The health promoting college (8) that reported on a major study of a settings-based approach to 45
Purposeful opportunism emerged as a third way in social planning precisely to move on from these polarized positions. Purposeful opportunism suggests that, rather than constructing one grand system, scheme or plan that when (eventually) mobilized will bring about Table 1. Beattie’s fourfold grid applied to the health-promoting university Courses Services Facilities Policies Health information and advice-giving to reflect individual behaviour Personal counselling for health to support life review and change Administrative action for health to reform regulatory systems Community development for health to identify common ground and facilitate joint action Talks, films and seminars on health risks, such as stress, smoking and HIV/AIDS Discussions and role play on peer pressures and social skills in health such as sex and HIV, drugs, etc. Assignments and projects that explore and assess the health profile of the university Programmes of adult and community health education and of local outreach Exhibitions and events and information packs on current health topics Opportunities and support for and self-help Channels for information exchange about issues related to being a healthy university Meetings, forums, fairs and street events to open up debate and decisionmaking on a health agenda across the university Space and resources for health education and preventive action Facilities for selfhelp and group activity Design, labelling, sign-posting and way-finding to support the healthy campus idea Provision for dual and multiple use of space and resources: a healthy university is an open university? policies on individual risks such as smoking, stress and personal safety Policies to support staff who need to adapt to new rules and codes such as those related to smoking Fully worked out university policies and rules on health agreed with students and staff Explicit and open structures for on health as an aspect of the corporate ethos and quality of life
Box, V. & Mahoney, P. An evaluation of the re-location of the certificate in health education from Tottenham College to Parkside Health Promotion Department 1987–88. London, Health Education Authority, 1988. Farrant, W. & Joffe, M. Fresh roles: a programme of medical student projects on health promotion policy in Paddington and North Kensington. London, St Mary’s Hospital Medical School, 1987. Farrant, W. “Health for all” in the inner city – exploring the implications for medical education. In: Falk-Whynes, J., ed. Health education in universities. London, Health Education Authority, 1991, pp. 21–31. Beattie, A. Developing a portfolio for health research. Lancaster, Centre for Health Research, 1992. Beattie, A. Teaching and learning about health education: new directions in curriculum development. Edinburgh, Scottish Health Education Group, 1990. CERI. Health, higher education and the community: towards a regional health university. Paris, Organisation for Economic Cooperation and Development, 1977. O’Donnell, T. & Gray, G. The health promoting college. London, Health Education Authority, 1993. Beattie, A. Knowledge and control in health promotion: a testcase for social policy and social theory. In: Calnan, M. et al., ed. Sociology of the health service. London, Routledge, 1991, pp. Beattie, A. The health promoting school: from idea to action. In: Scriven, A. & Orme, J., ed. Health promotion: professional perspectives, Basingstoke, Macmillan, 1996, pp. 129–143. Klein, R. & O’Higgins, M. Social policy after incrementalism. In: Klein, R. & O’Higgins, J., ed. The future of welfare. Oxford, Blackwell, 1985, pp. 223–230. Grossman, R. & Scala, K. Health promotion and organizational development: developing settings for health. Vienna, IFF/Health and Organizational Development, 1993 (WHO European Health Promotion Series, No. 2). Baric, L. Health promotion and health education practice. Module 2: the organisational model. Cheshire, Barns Publications, 1994.
The university as a setting for sustainable health University of Central Lancashire Mark Dooris BACKGROUND: ROOTS AND INSPIRATION The roots of the University of Central Lancashire’s project stretch back over several years. In 1992, the University was instrumental in Preston Acute Hospitals being selected as the pilot project for England within the WHO European Health Promoting Hospital initiative. Following representation on the Steering Group of this project, the University organized an international seminar on the settings-based approach to health promotion in collaboration with WHO and the North West Regional Health Authority (1). This seminar served as a catalyst within the University, leading to a growing interest in exploring the potential for applying the settingsbased approach within the institution itself. This interest was nurtured by the presence of a forward-looking Department of Health Studies within a Faculty of Health, whose understanding of health and health promotion drew extensively on health for all (2), the Ottawa Charter (3) and Antonovsky’s salutogenic focus (4). In 1995, Faculty research funding was secured to appoint a Health Promoting University Project Coordinator, initially for two years, which was subsequently made into a permanent post. CONCEPTUAL FRAMEWORK The first task in establishing the Health Promoting University Project was to clarify its conceptual basis – defining the essential characteris-
enthusiasm and available resources and to identify real-life entry points within the constraints of the existing organizational culture. Organizationally, the work was structured in a number of ways. Contributions to corporate and parallel initiatives The Project Coordinator and Project Steering Group carried out or supervised a number of opportunistic pieces of work, enabling the project to contribute to ongoing or planned institutional initiatives. In addition, the Project Coordinator has sat on both the Environment Committee and Ethics Committee, facilitating the integration of a health perspective into broader University structures. Task groups For several specific pieces of work, short-term task groups were established to achieve defined outcomes. Working groups Four issues were identified as appropriate foci for longer term Project working groups: sexual health, healthy and sustainable building design, transport and mental wellbeing. The selection was made pragmatically concerning relevance, interest and expertise, opportunities and resources – and the groups were set up sequentially, to avoid overload. Sexual health The Sexual Health Working Group was established in April 1996 – in acknowledgement of the clear relevance of sexual health issues to the University setting, in recognition that the University had not previously demonstrated a corporate commitment to addressing the issues and in response to offers from key external agencies keen to invest resources in the University. Healthy and sustainable building design The Healthy & Sustainable Building Design Working Group was initially convened in June 1996 following discussions between the Project Coordinator and Property Services – which concluded that there was substantial scope for developing and implementing a health and
taking an active role in networking, for example, with other universities. Examples of process output are demonstrated in Table 3. Table 3. Examples of output reflecting the process of projects Evidence of: Demonstrable through output such as: Adoption of the underlying philosophy and values High profile of health • • • • The steering group membership reflects the range of stakeholders in the project Equity is a guiding principle in selecting priorities for action Media coverage (internally and externally) Newsletters • Annual reports Management com- mitment to the project • • • • The university has a published health profile University policy and mission statements Resources are reallocated to the project Health needs are assessed • An exercise to develop a shared vision of the university Structural changes • • Agreed evaluation strategies and protocols New organizational structures • Relevant staff development (courses and training) Networking • • • • • Alliances for health with external agencies Journal and newsletter articles and publications Contributing to fund-raising for networking Cooperation with other universities at the regional, national and international levels Participation in the meetings and conferences of national and international networks IMPACT OUTPUT The impact of the project can be demonstrated through output in the eight objectives, taking account of any priorities or targets set in first phase of the project (Table 4). Finally, time and special effort should be invested in the process of starting a project. Preparing the basis for acceptance and support within the university before launching a project on a large scale is essential.