Settings for Health Promotion: An Analytic

Framework to Guide Intervention Design

and Implementation
Blake Poland, PhD
Gene Krupa, PhD
Douglas McCall, BEd

Taking a settings approach to health promotion means

addressing the contexts within which people live, work, > INTRODUCTION: PUTTING
and play and making these the object of inquiry and CONTEXT AND CAPACITY BACK
intervention as well as the needs and capacities of peo- INTO BEST PRACTICES
ple to be found in different settings. This approach can
Health promotion is increasingly cast as requiring
increase the likelihood of success because it offers
the identification of best practices through careful and
opportunities to situate practice in its context. Members
rigorous empirical evaluative research and applying
of the setting can optimize interventions for specific
these as faithfully as possible in practice (deviating as
contextual contingencies, target crucial factors in the
little as possible from what works according to the evi-
organizational context influencing behavior, and render
dence). Practitioners might be forgiven for feeling that
settings themselves more health promoting. A number
at times what is implied is both the possibility and the
of attempts have been made to systematize evidence
desirability of one-size-fits-all interventions and that
regarding the effectiveness of interventions in different
the significance of place has become all but irrelevant.
types of settings (e.g., school-based health promotion,
Yet thoughtful and engaged practitioners everywhere
community development). Few, if any, attempts have
know this logic to be flawed. Interventions wither or
been made to systematically develop a template or
thrive based on complex interactions between key per-
framework for analyzing those features of settings that
sonalities, circumstances, and coincidences. These
should influence intervention design and delivery. This
include, but are not limited to, timely funding opportu-
article lays out the core elements of such a framework
nities, changes in leadership, ideas whose time is right,
in the form of a nested series of questions to guide
organizational constraints, available resources, and
analysis. Furthermore, it offers advice on additional
local history of management–labor relations. In other
considerations that should be taken into account when
words, no two settings are alike. Ergo, at a minimum,
operationalizing a settings approach in the field.
allowances must be made for the uniqueness of settings
across time and space.
Keywords: settings; analysis framework; health pro-
A settings approach to health promotion has been
motion; school health
widely advocated as offering opportunities to situate

Authors’ Note: We would like to acknowledge the contributions of

Michael Polanyi, Ann-Sylvia Brooker, and Helen Madill (our coin-
structors for 1 or more years), as well as the students of HPS505/
CHL7001 Health Promotion Settings and Strategies, an online gradu-
ate seminar (University of Alberta–University of Toronto joint ven-
Health Promotion Practice ture). Please address correspondence to Blake Poland, PhD, Dalla
October 2009 Vol. 10, No. 4, 505-516 Lana School of Public Health, University of Toronto, 6th floor,
DOI: 10.1177/1524839909341025 Health Sciences Building, 155 College Street, Toronto, Ontario,
©2009 Society for Public Health Education Canada M5T 3M7; e-mail: [email protected].

505
 Goumans & Springett, 1997; Hancock, 1987, 1988;
Tsouros, 1995; WHO, 1992), prisons (Gatherer, Moller, &
The Authors
Hayton, 2005), and islands (Galea, 2000).
Blake Poland, PhD, is Associate Professor in the Dalla Through a careful analysis of the intervention set-
Lana School of Public Health and Co-Director of the Urban ting (be it the home, community, school, or workplace),
Environmental Health Justice Research Group at the Centre practitioners can forestall the possibility that a crucial
for Urban Health Initiatives, Toronto, Ontario, Canada. oversight could wash their project up, stall progress, or
make them seem naive and out of touch with local
Gene Krupa, PhD, is a Consultant in health promotion reality. This usually involves more than simply tweak-
and an instructor at University of Alberta and University ing a standard intervention protocol to make it fit in a
of British Columbia, Kelowna, British Columbia, Canada.
particular setting. To optimize the likelihood of suc-
cess (buy-in, organizational and personal change, etc.),
Douglas McCall, BEd, is the Coordinator of the International
School Health Network, Surrey, British Columbia, Canada.
careful stock must be taken of the local place-specific
context of intervention. A detailed analysis of the set-
ting (who is there; how they think or operate; implicit
social norms; hierarchies of power; accountability
mechanisms; local moral, political, and organizational
practice in its social context, optimize interventions for culture; physical and psychosocial environment;
specific contextual contingencies, target crucial factors broader sociopolitical and economic context, etc.) can
in the organizational context influencing behavior, and help practitioners skillfully anticipate and navigate
render settings themselves more health enhancing potentially murky waters filled with hidden obstacles.
(Baric, 1993; Frohlich & Poland, 2007; Poland, Green, & We wish to underscore that we do not advocate throw-
Rootman, 2000; St. Leger, 1997; Whitelaw et al., 2001). ing the baby out with the bath water; rather than being
A settings approach to health promotion is an orienta- dismissive of the intent behind, or thrust of, the move-
tion to practice that organizes it in relation to the envi- ment toward best practice or evidence-based practice,
ronments in which people live, work, and play. Inspired we seek a modest but, in our view, essential reframing
in part by the work of Aaron Antonovsky on salutogen- that acknowledges the importance of learning from the
esis (1996; Kickbusch, 1996; Poland, 2008), as well experiences of others (through many forms of both
as ecological approaches (Hancock, 1985; McLeroy, rigorous and anecdotal evidence) and also the impor-
Bibeau, Streckler, & Glanz, 1988; Richard, Potvin, tance of assessing and comparing the circumstances
Kischuk, Prlic, & Green, 1996), a settings approach and contexts in which outcomes were achieved else-
views the physical, organizational, and social contexts where with those pertaining to the setting in which an
in which people are found as the objects of inquiry and intervention is being proposed (or what is called
intervention, and not just the people contained in or assessing transferability in case study research). A set-
defined by that setting. Its emergence stems in part tings approach is envisaged not as a substitute for
from the recognition that arguably, the bulk of health evidence-based best practice but rather as an essential
promotion practice has been oriented to such settings component thereof (Poland, Lehoux, Holmes, &
(schools, workplaces, communities) and seeks to Andrews, 2005).
increase the sophistication with which knowledge A number of attempts have been made to systema-
about settings is mobilized in the planning, implemen- tize evidence regarding the effectiveness of interven-
tation, and evaluation of health promotion interventions tions in different types of settings (e.g., school-based
(see also Wenzel, 1997). Widely promulgated by the health promotion, community development). A few
World Health Organization (WHO), health-promoting have recommended frameworks for conceptualizing
networks and groups of researchers and practitioners and organizing practice (e.g., Lee, Cheng, & St. Leger,
have formed around schools (Deschenes, Martin, & 2005; Paton, Sengupta, & Hassan, 2005; Whitelaw et
Hill, 2003; Lister-Sharp, Chapman, Stewart-Brown, & al., 2001). However few, if any, attempts have been
Sowden, 1999; St. Leger, 2001; Stewart-Brown, 2006; made to systematically unpack those aspects of set-
WHO Expert Committee on Comprehensive School tings that matter most to an understanding of the vari-
Health Education and Promotion, 1997), universities ability of health promotion practice, as well as to the
(Dooris, 2001), workplaces (Chu et al., 2000; Polanyi, experiences of intervention participants, in a way that
Frank, Shannon, Sullivan, & Lavis, 2000; WHO, 1999), could directly impact policy, practice, and research.
hospitals (Johnson & Baum, 2001; Pelikan & Lobnig, The need to revisit our basic starting points in assess-
1997; Wise & Nutbeam, 2007), cities and communi­ ing health promotion effectiveness has been under-
ties (Ashton, 1992; Davies & Kelly, 1993; Duhl, 1986; lined in recent reviews of school health promotion

506 HEALTH PROMOTION PRACTICE / October 2009

research (Deschenes et al., 2003; Macdonald et al., There is something significant about the CATCH
1996; McCall, 2004; Rowling & Jeffreys, 2006) that interventions that we need to take into account if we
have called for new ways to understand the compre- are to sustain such programs. The school setting is sim-
hensive approaches and coordinated programs being ply unable to sustain high-profile programs like CATCH
delivered in complex environments. without changing many of the practices within that
Furthermore, policy makers and researchers setting. And it is not as simple as telling teachers what
(Scheirer, 2005; St. Leger, 2005; Stokols, 1996) are now to teach and how to teach it. The framework presented
calling for new ecological forms of analysis that can in this article provides a way of starting that process.
explain how multiple, coordinated programs can be In this article, we lay out the core elements of a tem-
sustained after external funding or expert technical plate or framework that could be used by practitioners
support is reduced or withdrawn. Calls for capacity to systematically analyze those features of settings that
building in health promotion (Best et al., 2003; McLeroy, can have the strongest impact on intervention design
2006; O’Loughlin, Renauld, Richalrd, Gomez, & Paradis, and delivery. We present this in the form of a nested
1998) are echoed by new approaches centered on con- series of questions to guide analysis. We have used one
tinuous improvement in education (Fullan, 2001; of the settings most often studied in the research, the
Galbraith, 2004; Reilly, 1999; Sanders et al., 2004; school, to illustrate aspects of the framework. Further­
Senge, 1990; Zmuda, Kukils, & Kline, 2004). more, we offer advice on additional factors that should
The deficiencies of this controlled, linear thinking be taken into account when operationalizing a settings
approach is illustrated by one of the largest interven- approach in the field.
tion studies ever completed on coordinated approaches The impetus for evolving the framework and writing
to school health promotion. The Child and Adolescent this article arose from the authors’ experiences in devel-
Trial for Cardiovascular Health (CATCH) was the larg- oping and implementing a graduate-level course titled
est school-based field trial ever sponsored by the Settings and Strategies for Health Promotion.1 We wanted
National Institutes of Health in the United States. The to create a framework for guiding analysis and, eventu-
CATCH coordinated set of interventions included (a) ally, intervention design, implementation, and evalua-
classroom instruction guided by a specific curricu- tion. Questions raised in the concluding chapter of
lum supplement, (b) family component, (c) physical Poland et al. (2000) were expanded, organized, and refi­
education curriculum supplement, (d) a food service ned over a 2 year period. As we applied them in practice
component (Eat Smart), and (e) a smoke-free school settings, and with graduate health promotion students
policy. Results from the main trial showed that chil- across Canada (most were practitioners as well), we saw
dren from CATCH schools had lower consumption of the potential for contribution to the field.
fat and higher levels of self-reported physical activity.
Retrospective analysis of the CATCH study (Heath &
Coleman, 2003) showed that institutionalization had
> THE FRAMEWORK
occurred after a few years. Perry et al. (1997) also The analytic framework we are advancing comprises
found strong correlations bet­ween the positive health three parts: (a) understanding settings, (b) changing
outcomes achieved and effective implementation. settings, and (c) knowledge development and knowl-
Participation, dose, fidelity, and compatibility in the edge translation. Each of these is discussed below, in
implementation of food service and physical activity the course of which the rationale for this way of organ-
programs in 56 schools in four states were measured izing the material is clarified.
and found to be correlated with successful program As noted above, the proposed framework is constructed
effects. Hoelscher et al. (2004) reported on the main- of a series of questions that practitioners can pose (of
tenance of the CATCH coordinated program. This themselves and of stakeholders) to better understand the
study compared 56 former CATCH and 40 former con- culture, history, and unique context of each intervention
trol schools as well as 12 new schools defined as the setting. Posing questions invites wider participation in the
unexposed control group and found no significant (co)learning process and is less prescriptive than frame-
posttrial differences in school menus or in time works that more tightly specify what is to be included and
assigned to physical education. At follow-up, about how. By framing questions, we acknowledge there are
one third of the original CATCH and control schools multiple perspectives and answers and that this diversity
were still using the CATCH materials. Furthermore, can be helpful rather than obstructive. For this reason,
as with many other successful programs, the founda- although the analytic framework that we advance in this
tion that had been supporting the CATCH program in article may be used as a rough, quick assessment tool prior
its home state of Texas has now decided to end that to work involving people in a setting, it should ultimately
funding. be used with the people in the setting themselves. These

Poland et al. / SETTINGS FOR HEALTH PROMOTION 507

 TABLE 1
Understanding Settings

Diversity across and within categories of settings

  1. What makes this category of setting (e.g., hospitals) different from (or similar to) other categories of settings
(e.g., schools, workplaces)?
  2. What diversity can be expected within this category of setting? (e.g., inner city vs. suburban or rural schools;
large, corporate vs. small, family-run workplaces, etc.)
Received knowledge
  3. What assumptions are usually made about this setting? Are these assumptions warranted in this case?
  4. How has the conceptualization (as well as role and nature) of this setting evolved over time?
Localized determinants of health
  5. How does the setting interact with other related settings and systems as well as the local environment to
accomplish its goals?
  6. What elements of the physical and built environment are causing ill health in this setting? (ergonomics, noxious
hazards, physical and social isolation or lack of opportunities for interaction, access to green space, etc.)
  7. To what extent do the following aspects of the psychosocial environment have a bearing on health and the
possibilities for intervention in this setting?
• social composition with respect to age, gender, race, and class
• stress, decision latitude, control over pace, and demands of work
• status hierarchies
• work–life balance
• behavioral norms and expectations (social sanctions)
• quality of human relations (trust, reciprocity, local social capital and social cohesion, bullying)
• lines of accountability and reporting structures
• organizational culture and readiness for change
• internal politics, recent history of accommodation, or prior conflict
Stakeholders and interests
  8. Who are the primary stakeholders in this setting or affecting this setting?
  9. What are their agendas, their stake in change or the status quo, access to resources?
10. What are the functions of this setting for different stakeholders (e.g., hospital functions as site of healing for
patients, home for long-term or palliative care patients, workplace for staff, site of professional and class
conflict)
11. Who is absent from this setting? Why?
12. What is the meaning of health from different stakeholder perspectives and its salience to them?
13. How widely are the determinants of health as they are experienced in this setting understood and acted on?
Power, influence, and social change
14. How do power relations come into play in this setting?
15. What is the relative power of stakeholders? How is power exerted?
16. Who controls access to this setting?
17. Who sets the agenda in this setting?
18. Who participates in decision making? On what basis? On whose conditions?
19. Who has voice? What is the relative role and power of experts and of the lay public in agenda setting, problem
definition, intervention planning, implementation, and evaluation?
20. What—or who—drives (or blocks) change in this setting?

questions can be used to build capacity for analysis as well designed to highlight and focus attention on a different
as a way of opening discussion. aspect of a setting that we maintain requires considera-
tion in program planning and implementation (see Table 1).
The questions on understanding settings are grouped
Understanding Settings according to the issues and dimensions they address, as
The first component of our framework comprises 19 follows: (a) differences and similarities across types of
questions organized under five subheadings, each settings, (b) unpacking assumptions, (c) identifying

508 HEALTH PROMOTION PRACTICE / October 2009

localized determinants of health, (d) mapping stake- life changes based on class, gender, and race (Gatto,
holder interests, and (e) add­ressing power relations. 1992; Illich, 1971). In essence, schools are supposed to
fail about 10% to 15% of their students each year.
Differences and similarities across types of settings. There is pressure on schools to perform in this respect,
The analysis of settings can be enhanced by first of all with standardized tests and school rankings. And when
considering certain types (categories) of settings and people are not successful in a given environment, they
what they have in common. For example, what distin- tend to withdraw or act out within that environment.
guishes schools from hospitals or other settings? There This detracts from another important function that
are enduring features of types of settings (e.g., schools) schools are expected to play, the socialization of young
by virtue of their standardized structure, position in an people as team players.
institutional field or system, systematized routines, Lately, assumptions regarding the nature of organi-
social role, legal standing, etc. Understanding these zational development, the nature and role of leader-
enduring features helps practitioners to initially orient ship, and the management of change have been turned
to a setting as a form of a broader type. upside down by complexity science and its application
From this understanding of common features, practi- to social systems (e.g., Holling, 2001), organizational
tioners must appreciate the diversity that lies behind change management in the health (Begun, Zimmerman,
the apparent homogeneity. For example, not all schools & Dooley, 2003; Plsek & Wilson, 2001; Zimmerman,
are alike. Even those within a publicly funded system Lindberg, & Plsek, 2001) and other sectors, with impli-
operate in different neighborhood environments, have cations for the settings approach (Dooris et al., 2007)
different racial and social-class mixes of students and and the broader community and social change efforts
teachers, evolve from different local histories, and (Westley, Zimmerman, & Patton, 2006).
­experience different levels of parental involvement. When such assumptions are made explicit, stake-
Prin­cipals lead with different styles, staff members have holders both within and outside the setting have the
different skills and sensitivities, and parent organiza- opportunity to question its wisdom or to distance
tions vary in effectiveness and influence. Schools have themselves from it. This can create new openings for
different physical attributes (size, access to public trans- more participatory approaches or at least a better
port, etc.) that influence access, and so on. As well, understanding of the constraints within that setting.
those working in schools will find considerable diver-
gence about methods, even about basic issues such as Localized determinants of health. Elements of the phys-
how to teach reading. Some professional environments, ical, built, and psychosocial environments often consti-
such as schools, may discourage peer learning by allo- tute risk conditions that can have a profound impact on
cating little time for staff exchanges and joint planning health. Assessing these may clarify potential targets for
or may have professional norms that see collegial intervention, limits on what interventions may be pos-
exchanges as being contrived (Tuohy & Coghlan, 1997). sible, and any need to go beyond the boundaries of the
setting to effect change. Questions 6 and 7 in Table 1
Unpacking assumptions. Explicit and tacit assumptions provide examples of elements to examine in the local
are usually made about the setting, both by insiders and environment.
by outsiders. It is important to articulate these and to The interactions between the school setting and its
consider their validity and appropriateness or helpful- external environments (families or parents being served,
ness. It is also instructive to consider how the setting is neighborhood, school board, other agencies, govern-
conceptualized by members and how that may change ment ministries, etc.) have been described by several
over time. These can influence possibilities for inter- researchers. Flay (2002) suggests that the school setting
vention and have implications for process. is almost inseparable from the community and families
For example, there is often a tacit assumption that it serves. Cook, Herman, Phillips, and Settersten (2002)
schooling is something that is done to or for students assessed some of the ways in which neighborhoods,
but not necessarily with them. And although there is families, friendship groups, and schools jointly effect
considerable attention now being paid to the social changes in early adolescent development.
environment of schools, with evidence now accumulat- On the other hand, others (Ozer, 2006) have sug-
ing in mental health studies that show health and aca- gested that the school has little long-term autonomy
demic benefits derived from a caring school environment, from the prevailing social norms and economic con-
this can lead to simplistic calls for teachers to be more straints of its local context and community. Schools
caring. At the same time, however, schools are expected serving aboriginal, disadvantaged, rural, and religious
to sort and stream young people into future careers, will face different constraints when they implement
allocating distinction and in many cases reinforcing school health programs, Ozer (2006) argues.

Poland et al. / SETTINGS FOR HEALTH PROMOTION 509

Stakeholder interests and power relations. A detailed specific setting. What efforts have been aimed at chang-
analysis of the stakeholders and vested interests in the ing behaviors within this kind of setting or changing
setting is essential. This mapping of the sociopolitical the setting itself? How have approaches changed over
landscape helps determine who to work with and how time, and how might we explain these changes?
to work with them, insofar as one is able to identify For example, school health promotion has evolved
stakeholders who may be expected to support, resist, or from medically driven, curriculum-focused exhorta-
remain neutral to the proposed intervention. This, tions to teachers to teach facts about single health
combined with an assessment of the relative power of issues. Subsequently, more comprehensive approaches
these resistors and supporters—who controls access, (linking different clusters of health problems and fac-
who sets the agenda, who has a voice, who participates tors), and then coordinated programs (across several
in decision making (and on whose terms), and who systems and at different levels within those systems),
drives (or blocks) change in this setting?—allows the have given way most recently to whole-school approaches
practitioner to be strategic in how she or he works that emphasize multiple policy, educational, service,
within what are often complex and politically charged and environmental interventions. Funding for research
social environments. and policy making has not always kept up with these
Schools have been described by many as open, loosely new understandings.
coupled, and bureaucratic systems (Fusarelli, 2002; In addition to the prior analysis of the setting
Griffith, 2003; Lam, 2004; Weijck, 1982). These charac- (Table 1), we ask what the health promoter brings to
teristics have a bearing on how decisions are made this particular setting—the skills, capacities, resources,
within school systems. For example, in open, bureau- and sensitivities of relevance. This includes similari-
cratic systems, the role of the middle manager will ties or differences with key stakeholder groups (e.g.,
often be focused on maintaining boundaries within and race, class, gender, physical ability, sexual orienta-
external to the system. Some studies have examined tion) that may act as points of friction or affinity. An
the perceptions of school principals with regard to analysis of the context for change efforts must also
various health issues but few studies have examined grapple with what supports must be in place (or bar-
how the role of the principal in school health promo- riers removed) outside the setting in the broader
tion can be successfully influenced. sociopolitical, community, and/or economic context.
In our experience, a common question that is raised This may necessitate work in advocacy, coalition
at this point is, Who does this analysis? Our response building, strategic partnerships, or deepening and
is that questions need to be addressed with people in widening community participation, including vital
the setting. In health promotion practice, participation work across settings—what is currently referred to as
at a high, “ownership” level is an ideal that is not “joined up” settings work (Dooris, 2004).
always attainable. But in most cases it is a worthy goal.
Our experience is that stakeholder analysis of the set- Capacity. The capacity of the setting for change should
ting may be facilitated at several points during the be considered as well. Dimensions of community,
process and that it deepens as capacity for analysis ­professional, agency, government, and overall system
increases and as the process reveals previously hidden capacity have been identified in studies such as those
dynamics. This also reflects a commitment to “starting connected with the Canadian Heart Health Strategy
where the people are” while also building capacity for (Elliot, Taylor, Cameron, & Schabas, 1998). For schools,
deepening the social analysis (we take up this issue the WHO (2003) has identified several relevant capaci-
later in this article). ties, and these have been adapted and used here in
Canada by the School Health Research Network (McCall,
Changing Settings 2004). These capacities include

We have organized the design questions in Table 2 • coordinated policies across several systems that
into six groupings: context, capacity, focus, engage- influence the setting;
ment, strategy, and evaluation. The order corresponds • infrastructure and assigned staffing to support coor-
roughly to the sequence in which these issues arise in dination of multiple programs;
practice, although there is an element of recursivity • formal and informal mechanisms for cooperation
that also needs to be acknowledged. across systems and professions;
• ongoing workforce development;
Context. One is asked to consider the history of health • ongoing knowledge exchange, transfer, and
promotion efforts in the category of setting, then the development;

510 HEALTH PROMOTION PRACTICE / October 2009

 TABLE 2
Changing Settings

Context
  1. What is the history of health promotion in this setting?
  2. What explains the changing approaches to this setting?
  3. What does the health promoter bring to this work? (background, training, skills and abilities, sensitivities,
assumptions; also similarities or differences in terms of race, class, and gender with respect to key stakeholder
groups and the impacts this may have on practice)
  4. What is the role of the broader sociopolitical context in supporting or limiting change efforts? Is there a need for
higher level policy change and advocacy work across settings and locales?
Capacity
  5. What capacities are required among professionals for this setting to promote health effectively?
  6. What capacities are required within local communities to make this setting effective?
  7. What capacities are required among local agencies for this setting to be effective?
  8. What capacities are required among governments for this setting to be effective in promoting health?
Focus
  9. How should one select which setting to work in?
10. What emphasis should be given to physical health, as distinct from (but clearly related to) emotional, mental,
and spiritual dimensions of health?
11. Should one direct interventions to those with power and privilege or to those who are relatively less
advantaged?
Engagement
12. What are the issues involved in engaging in this setting? (negotiating and gaining entry, developing trust,
managing relationships and competing agendas, etc.)
13. How will you successfully manage (sometimes competing or unrealistic) expectations regarding intervention in
this setting?
Strategy
14. What emphasis is put on changing individual behavior as opposed to structural and organizational change?
(changing persons in the setting and/or changing the setting itself to become more health promoting)
15. How should one work with broader and indirect stakeholders outside the setting of focus? (e.g., role of families
in shaping the behavior of school-yard bullies)
16. How participatory an approach are you willing to undertake? Whose participation will be sought, and how will
differences in agendas and power of different stakeholders be handled?
17. What (types and nature of) evidence is drawn on in intervention design? How is local experience and local
input blended with evidence-based practice to produce optimal interventions?
Evaluation
18. How do we (and other stakeholders) define and measure the success of a health promotion intervention in this
setting?
19. What unintended consequences (positive and negative) can be identified?
20. What is known about the distribution of costs and benefits associated with this intervention in this setting?
(equity and social justice considerations)

• regular monitoring and reporting on progress; communities and an opportunity to put the process in
• explicit procedures to identify emerging issues and the hands of those in the setting. However, we recog-
trends and priorities; and nize that because of the context, it may take some time
• explicit plans for sustainability. to realize the goal of internal direction. The question of
whether to work with or around power (see above) is a
Focus. To focus the intervention, we have included key issue to be addressed, although it is not always
questions that address the basis on which practitioners, made an explicit choice.
in consultation with others, select (a) the setting, (b) the
issues, and (c) the priority population. Issue selection is Engagement. This phase of the work involves strategic
a key step in health promotion and development with choices. One may negotiate entry in a variety of ways,

Poland et al. / SETTINGS FOR HEALTH PROMOTION 511

 TABLE 3
Knowledge Development and Knowledge Translation

1. What do we still need to know about the settings approach? About this setting in particular?
2. What forms of knowledge and information allow one to understand this setting? What counts as legitimate
knowledge and who participates in its creation and dissemination?
3. What gaps can be discerned between theory and practice? Are we successfully “walking the talk”?

depending on the context and focus. In a corporate set- grassroots participation, community development, and
ting, one could, for example work through powerful empowerment approaches; and lastly (e) a “compre-
gatekeepers such as business owners. They may facili- hensive” model that seeks fundamental and enduring
tate access but could also try to control the agenda. change in setting structure and culture through the use
Alignment with those in power may alienate you from of powerful leaders and policy levers. Our proposed
other stakeholders such as unions and shop floor work- framework invites anguish on this. We promote diverse
ers. Building trust with multiple stakeholders may stakeholder participation and broadening the scope to
require declaring allegiances and demonstrating these consider changes needed beyond the setting to cata-
through tangible action and taking risks. There will be lyze, support, and sustain change within the setting.
choices about how to manage relationships, competing We also advocate for reflexivity concerning the
agendas, and competing and/or unrealistic expecta- nature of evidence that informs intervention design,
tions associated with the intervention in a particular including the tradeoffs that will be made between sci-
setting. Some stakeholders may be overly optimistic entific evidence (e.g., best practices) and local lay
and others pessimistic about the prospects for change knowledge, experience, and preferences.
based on prior failures or successes, or see your inter-
vention as a test or answer to other problems in the Evaluation. Last but not least, change efforts within set-
setting—giving you additional baggage to handle. tings must grapple with how different stakeholders
Not explicitly specified in our model, but often define and measure success in health promotion inter-
equally important, is the issue of disengagement. ventions. Much has been written on the evaluation of
Tentative advance decisions about how to transfer health promotion initiatives. It is not our intent to
ownership, fulfill promises, and when to withdraw reproduce or wade into that here. However, we recom-
from a setting can be helpful to all involved. mend two additional considerations at this stage that
­Prac­titioners should also be aware that when interven- are less often discussed in the evaluation literature:
tions do not go well or expectations for change are (a) an examination of unintended consequences (both
dashed, they risk being made scapegoats from one or positive and negative) and (b) the relative distribution
more sides. of costs and benefits resulting from the intervention
across stakeholder groups. This links directly to the
Strategy. Issues of strategy take their cue from prior ideology of health promotion and attentiveness to
analysis of context, and decisions regarding focus and issues of equity and social justice as foundational in
engagement, and are informed by other questions. For health promotion practice.
example, what emphasis will be put on individual
behavior change versus structural or organizational
Knowledge Development
change, or changing those in the setting versus chang-
and Knowledge Translation
ing the setting itself? Whitelaw et al. (2001) outline five
different types of settings-based health promotion prac- The questions in this final component of the frame-
tice: (a) a “passive” model, wherein the setting is seen work address the identification of gaps in our knowl-
as a convenient way of targeting traditional health edu- edge about settings and the settings approach (including
cation to a “captive” audience; (b) a more “active” how knowledge is built over time) as well as the inter-
focus on individual behavior change that incorporates face between knowledge (production, dissemination)
some attention to organizational or systemic enablers and practice (Table 3). This latter dimension includes
and barriers; (c) a “vehicle” model that involves tangi- not only knowledge translation as that has been
ble projects that target aspects of the setting itself seen recently understood but also a closer examination of
to require modification; (d) an “organic” model that the extent to which we are able to walk the talk in
also focuses on healthy settings but does so through health promotion. Unless health promotion practice is

512 HEALTH PROMOTION PRACTICE / October 2009

empowering, laudable rhetoric remains empty rheto- 2. Look for unanticipated effects and unintended con-
ric. This latter point is not trivial, insofar as health sequences (both positive and negative).
promotion has been accused from several quarters of 3. Be reflexive regarding ethics associated with actions,
failing to translate a liberal and enthusiastic use of assumptions, and use of power. Begin with one’s
concepts like empowerment into practices that have a own (assumptions and actions) and expand to
demonstrably empowering impact. This has led some include others.
commentators to wonder whether discourses of 4. Recognize the impact of race, gender, class, and age
empowerment and social justice serve to forestall differences between oneself and others, and among
criticism and cover for business-as-usual (Stevenson & others.
5. Develop a coherent, but nonlinear, ecological logic
Burke, 1992). Ideally these issues would be front and
model to describe and summarize our understand-
center in any program evaluation. Although much of
ing of how this intervention addresses the determi-
the evaluation literature seems to miss these issues,
nants of health in this setting, linking specific
there are a few exceptions (e.g., Fetterman, Kaftarian, intervention strategies to intermediate and longer
& Wandersman, 1996; Kahan & Goodstadt, 2001; term outcomes as well as to the stability and ongo-
Poland, 1996). Our strong recommendation would be ing core functions of the setting.
to pursue the historic ideals of health promotion (e.g., 6. Start where the people are, with their own self-­
ownership-level participation, empowerment) to cre- understanding and perspectives, but seek to deepen the
ate positive, sustainable change. social analysis of root causes that affect their health,
moving from the personal and individual to the orga-
> APPLYING THE FRAMEWORK nizational, community, and societal contexts.
7. Address how the setting itself can become more
Wherever possible, practitioners engage those living
health promoting and not just how the intervention
in—and having major stakes in—the setting in analyz-
influences the people to be found in the setting.
ing their setting. Ideal analyses are collective analyses 8. Link across and going beyond settings.
of a social setting in which the health promotion practi- a. identify relevant stakeholders and influences out-
tioner, participants, and stakeholders are colearners. side the setting.
Through the process, all should come to see things a bit b. identify the role of the broader sociopolitical con-
differently, increase their capacity for analysis, and feel text (and thus limits to change efforts, need for
an increased sense of empowerment. Emphasizing this higher level policy change, and advocacy work
latter point, appropriate forms of practice (e.g., Caplan, across settings and locales).
1993) would include an attempt at deepening the social
analysis, using approaches similar to the application of
Friere’s work to health promotion that emphasizes start-
ing where the people are but acting as a catalyst for
> CONCLUSION
working with people to move beyond their own taken- A settings approach is an attractive and eminently
for-granted (and sometimes self-defeating) assumptions feasible route to health promotion. An analysis of the
about themselves, the world, and their place in the world setting at an early stage can be helpful in organizing
(Minkler & Cox, 1980; Poland, 1992; Wallerstein & for action and optimizing the likelihood of success.
Bernstein, 1988; Wallerstein & Sanchez-Merki, 1994). ­Sys­tematic analysis can create valuable opportunities
This is why we also developed, for teaching purposes, for empowerment and capacity building with those in
a list of corollaries that we believe should underpin the setting as well as those in systems that envelop the
health promotion practice. These are grounded in a setting. In this article we have described a framework
particular value base that is articulated more fully by of critical questions for the analysis of settings that we
Nelson, Poland, Murray, and Maticka-Tyndale (2004). developed for teaching purposes and that has benefited
This value base is implicit in our framework and from input from practitioners and academic colleagues
reflected in the mix of questions. We also share these from across Canada. Its purpose is to assist in the plan-
here in our belief that they should be embraced in the ning, implementation, and analysis of health promo-
process of implementing a settings approach. tion interventions that incorporate, or take as their
point of departure, a settings approach—working on,
1. Account for the temporal patterning of behavior with, and through the settings in which people live,
(different seasons of activity, seasonal deadlines, work, and play. We maintain that a reflexive engage-
production cycles, business vs. after-hours uses of ment with issues such as stakeholder interests, power
the space, etc.). relations, implicit assumptions, and the evidence base

Poland et al. / SETTINGS FOR HEALTH PROMOTION 513

for interventions (only a few of the issues we raise) will effectiveness of whole systems health promotion—Challenges
make for more relevant, sustainable, and successful and future directions. In D. V. McQueen & C. M. Jones (Eds.),
Global perspectives on health promotion effectiveness (pp. 327-352).
interventions. This framework is currently being adapted
New York: Springer.
for use in Brazil and we look forward to reporting on
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welcome comments from readers, including sugges-
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tions for improvement, stories of application, and iden-
Assessing public health capacity to support community-based
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NOTE 607-622.
1. This Web-based course was a collaborative initiative between Fetterman, D. M., Kaftarian, S. J., & Wandersman, A. (Eds.).
the University of Toronto (Department of Public Health Sciences) (1996). Empowerment evaluation: Knowledge and tools for self-
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American Academy of Health Behavior. Prepared for acceptance
of the Research Laureate Medallion from the American Academy
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