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Settings-based approach to health promotion
Recently, the WHO updated physical activity recommendations (World Health Organization, 2020), providing guidelines for various age groups. Particularly relevant to this thesis within the update, the WHO points out the importance of building settings which can positively contribute to achieving these recommendations. The settings-based approach was first broadly introduced during the 1986 Ottawa Charter (World Health Organization, 1986) and has since evolved over the past 30+ years. Where initially, promoting health was based solely on the individual, the setting-based approach is defined as “the place or social context in which people engage in daily activities, in which environmental, organizational and personal factors interact to affect health and well-being” (Nutbeam, 1998). This approach provides an ecological perspective (Green et al., 2005) beyond the individual to consider the context of settings and how they can positively impact health. Much of the current research on settings has been done to develop the ‘whole system’ wherein and individual is part of the setting but the setting is built like a system (Whitelaw et al., 2001). Viewing a setting as a system helps to incorporate different levels; promoting health within the setting can begin at any level and requested changes in individual behavior and organizational behavior need to be in harmony with each other (Beer & Huse, 1972). Developing this ‘leveled’ approach requires that a model be applied to the setting. Previous research on common traits for models and frameworks used to implement settings-based interventions helped to create the aforementioned BCW. Among other factors, this ‘wheel’ again highlights the importance of policies and commitment. It also points out capacities of individuals and opportunities to promote health through social and physical interactions (Michie et al., 2011). Thus, the settings-based approach to health promotion was derived from the socio-ecological model of health considering how the environment (setting) strongly influences the health individuals (Golden & Earp, 2012). Thinking about the physical activity model from Booth (Booth et al., 2009) it can be reapplied to settings in the broader sense of health. Combining the BCW with this model gives a broader application to how the setting can influence individual’s health. It can, therefore, be concluded that multiple settings are a positive means for promoting health to various populations and are answering the WHO’s call. Because people live in multiple settings (i.e. education, work, recreation), work on promoting health in various settings is necessary and should be context specific but contain similar messages in line with those from various documents such as the Global Strategy on Diet, Physical Activity and Health or France’s National Health Strategy. The original socio-ecologic model has been successfully adapted in various settings to develop health promotion interventions. Settings such as hospitals, now dubbed ‘health promoting hospitals’, show evidence of how this setting underwent organizational change to re-orient by increasing health promotion activities (Johnson Baum, 2001) both for hospital staff as well as patients. The hospital setting reiterates how commitment to promoting health is at the forefront of organizational change and is a prime example of the transition from a deficit model to an assets model for promoting health (Morgan & Ziglio, 2007). Universities and schools are another area which have implemented settings-based health promotion tactics which focus on healthy behavior changes, identifying needs and providing resources (Dooris et al., 2014). Universities specifically pointed out the need to take culture into consideration while developing the health promoting school approach focuses on the health and well-being of all school users including teachers, administrative staff and students (Turunen et al., 2017). Health Promoting Schools include school policies, the physical and social school setting, provisions for promoting health literacy in the curriculum, family and community partners and the school’s health services (Schools for Health in Europe, 2014). Another example is the unique setting of prisons. The Health Promoting Prisons approach is committed to safe environments with respect for inmate’s human rights. Additionally, health-promoting prisons use a systems perspective by considering not only inmates but equally the health of staff members (Baybutt & Chemlal, 2016). On a grander scale, the Healthy Cities Programme was launched by the WHO to improve the environment of urban cities and provide a better quality of life for inhabitants. It was the main focus of the Global Conference on Health Promotion in 2016 in Shanghai. The programme helps managing and planning urbanization to control pollution, overcrowding, violence, mental illness, increased access to healthcare and nutritious foods (World Health Organization, 2016). It includes multiple phases with 11 primary tenants: 1) quality of the physical environment, 2) sustainable ecosystem, 3) supportive communities, 4) community participation for decision-making, 5) basic needs of the community members, 6) resource accessibility, 7) thriving economy, 8) cultural connections, 9) structed city to provide all of the aforementioned tenants, 10) strong public-health agencies and 11) low disease rates and high health status (de Leeuw, 2012). To make these settings more effective at promoting health, the actors within the setting need guidelines, step-by-step instructions. Instructions should not only include how to implement health promotion actions but why they should undertake it. Not only why it is important to improve health but reasons it helps the environment, whether it be in schools for children to help them learn or for better behavior while in classrooms or in prisons for inmates to have control over themselves when in-face of delinquent behavior which could include teaching them how to live outside the confines of the prison setting and better integrate into society. When healthy behaviors are adhered to, it also makes the environment better for other actors such as teachers or guards. This can have positive consequences such as keeping teaching or prison staff longer (retention benefits also leading to long-term economic benefits), better mental health with lower stress and anxiety. Common themes can be seen between these different settings: 1) they all have a context specific framework to guide research, policy development and implementation which may help improve efficacy (Dooris, 2006), 2) they seek to use a whole system approach recognizing that efforts should focus on the organization as well as all stakeholders involved and 3) they point out that organizational change and commitment is necessary for sustainability of these programs. These types of benefits can also be seen when translating into other settings such as sport which is a low cost, high impact tool to contribute to healthy societies by promoting health.
Current state of health promotion in sports clubs
Hospitals, schools and prisons are three solid cases of settings-based health promotion put into action. These act as examples to set the stage for research on leisure settings such as sports clubs to be addressed. With the many of the documents highlighting the need to direct attention to increasing physical activity and diet, sports clubs are a perfect context to develop as health promoting settings. The 2018 Eurobarometer reported that there are 16 million participants and 3 million volunteers in sports clubs (European Commission et al., 2018). Furthermore, there are over 100 sports federations with more than 700 000 associated sports clubs in Europe making sports clubs an ideal setting to promote health. To operationalize this setting, previous work has been undertaken to understand how sports clubs are organized. Although based on the individual and related to physical activity, when applied to the setting of sports clubs and thinking in broader health terms, a microcosm of Booth’s model (Booth et al., 2009) can be seen. Sports participants are at the center, impacted by their personal characteristics such as their motivation to participate in sport. Surrounding them, but still within the structure of the sports club, includes the sports club staff and fellow members while the policies of the sports club can be viewed as the outer most layer. Supporting this type of ‘layered’ approach to the sports club setting, work done by Kokko (Kokko, 2014b) used the settings-based approach by building a health promoting sports club (HPSC) concept with three sports club levels (club policies, officials, coaches) and four determinants of health (cultural, economic, environmental, social) (see Figure 3) (Kokko et al., 2014). Rather than applying the socio-ecological approach to a specific behavior such as physical activity and diet, as that of Booth (Booth et al., 2009), this concept applies it to the setting of sports clubs. It was with this initial research that the PROSCeSS project began to fill in the following short falls: 1) to fully develop the HPSC concept, 2) to redirect the primary focus from youth athletes to all sports club actors (participants, coaches, directors, volunteers, family members, etc.) and 3) to aim attention on broader perspectives of health rather than solely behavior change related to physical activity.
Framing the research questions and primary goals
The PROSCeSS project was framed around the HPSC vision and seeks to create a setting fully embracing health through policies and daily sports club actions. While models of behavior change place the individual at the core, this thesis is places attention on developing the setting in order to help the individual. Thus, the end result may be the same, but the focus is on the sports club setting to support the actors to make healthy choices through the club’s promotion and reinforcement of healthy behaviors. The project sought to fill in some of the current gaps and limitations in research for applying the settings-based approach to sports clubs and following the steps suggested in the intervention mapping protocol which has been used as a basis to plan and implement health promotion projects in psychology and social sciences (Kok et al., 2017). The settings-based approach is based on the knowledge that providing members, staff and even the surrounding community with a safe and healthy environment can go far beyond what is typically provided as a sports club’s core business. Keeping this in mind, the PROSCeSS project aims to support sports clubs in their efforts to increase health promotion actions. From this perspective, distinct gaps in current research were found: A lack of a validated measurement tool to evaluate the application of the settings-based approach within the sports club context. Current questionnaires focus on interviews or self-report tools (Casey et al., 2011), tool that were used were not qualitative, unvalidated measures (Geidne et al., 2019) or the tools were not culturally universal (Kokko et al., 2009).
Although there is a health promoting sports club concept, no theoretical model exists with a coordinating evidence-based framework to provide guidelines for policy development and implementation practice. This is important to achieve successful health promotion interventions (Michie et al., 2011; Peters et al., 2009). When health promotion interventions are implemented in the sports club context, theories to inform their design and evaluation are rarely specified (Rothman, 2004). Furthermore, providing a model of the sports club as a setting, gives intervention planners targets for levels and health determinants. A model demonstrates how the various levels interact and are interconnected to support each other in increasing health.
Multiple published documents and articles stress the importance of framing strategies to promote health (World Health Organization, 1986), implement programs in the sporting context (McFadyen et al., 2018) and build the organizational capacity of sports club actors to promote health (Casey et al., 2012). While guidelines exist, predominantly derived from youth sports club interventions (Geidne et al., 2019), no concrete strategies have been drafted for use in all grassroots sports clubs. Offering specific strategies for the sports club setting can help with developing policies and set health promotion interventions into practice (Dooris et al., 2014). Stakeholder ideas are valuable when developing settings-based health promotion interventions yet, seldom are their expectations or needs considered (Van Hoye et al., 2015). Collaborating with stakeholders by using a participative (bottom-up) approach can help to increase the acceptability and endorsement when framing policies, co-designing interventions and evaluating the outcomes (World Health Organization, 2015). It is an essential part of the intervention mapping process and should be considered throughout the planning, design, creation and evaluation steps (Kok et al., 2017). A lack of collaboration with sports club actors implementing health promotion programs exists in current research (Kokko et al., 2011; Van Hoye et al., 2015). This type of collaboration can help to gain the endorsement of sports club actors and gain and understanding of their expectations for health promotion programs within their club. In this way, adding a bottom-up approach to the currently available research increases the chances of success (Poland et al., 2009).
Table of contents :
Abstract
Résumé
Acknowledgements
Thesis linked publications and communications
Other related noteworthy publications
List of tables
List of figures
Glossary
Acronyms
GENERAL INTRODUCTION
CHAPTER 1: THEORETICAL BACKGROUND
1.1 The call for promoting health
1.2 Models for health promotion
1.3 Settings-based approach to health promotion
1.3.1 Current state of health promotion in sports clubs
1.4 The HPSC vision
1.4.1 Capacity building for organizational change
1.5 Framing the research questions and primary goals
CHAPTER 2: EXPLORING HEALTH PROMOTION PERCEPTIONS
2.1 Preparing for study 1
2.2 Study 1: Measuring Health Promotion in Sports Club Settings: A Modified Delphi Study .
2.3 Preparing for study 2
2.3.1 Study 2: French validation of the e-PROSCeSS questionnaire
2.4 Analysis & considerations
2.4.1 Practical implications
CHAPTER 3: CREATING A MODEL AND FRAMEWORK
3.1 Preparing for study 3
3.2 Study 3: The health promoting sports club model: An intervention planning framework
3.3 Preparing for study 4
3.3.1 Study 4: Building health promoting sports clubs: A participative concept mapping approach
3.4 Preparing for study 5
3.4.1 Study 5: A health promoting sports club framework: connecting participation with evidence
3.5 Analysis & considerations
3.5.1 Practical implications
CHAPTER 4: CAPITALIZING ON EXPERIENCE
4.1 Preparing for study 6
4.2 Study 6: Capitalization of health promotion initiatives within French Sports Clubs
4.3 Analysis & considerations
4.4 Practical implications
CHAPTER 5: DISCUSSION AND CONCLUSIONS
5.1 General discussion
5.1.1 The HPSC approach through the lens of intervention mapping
5.1.2 5-stage approach
5.1.3 The HPSC Logic Model
5.2 Development of the HPSC approach compared to HPS
5.3 Research perspectives
5.3.1 Public health perspectives
5.4 Implications for future research
5.4.1 Pilot study
5.4.2 Assessing the health determinants
5.4.3 Evaluation methods
5.4.4 Focus groups
5.4.5 MOOC
5.4.6 HPSC-NAT
5.4.7 Sports Federation development
5.4.8 Capitalizing on international projects
5.5 Conclusion
REFERENCES
