Embedding health and sustainability
With 169 higher education institutions and more than 2.3 million students and almost 365,000 staff (Universities UK, 2008), the UK higher education sector offers enormous potential for improving health and wellbeing.
It is challenging to introduce and integrate health and wellbeing within institutions that do not have this as their central aim – and it is, therefore, essential that Healthy Universities work is linked to universities’ core business and seen as a mechanism for delivering against strategic objectives in areas such as student recruitment, retention, experience and achievement; widening participation; staff performance and organisational productivity; and teaching, learning and research.
Whilst Healthy Universities is a relatively new area for research, it is possible to draw on research from other settings programmes, such as Healthy Schools and Healthy Further Education, which provides promising evidence that multi-component whole system approaches are more likely to be effective than single interventions and ad-hoc activities.
…a range of helpful models for understanding and implementing a whole system Healthy Universities approach
…background information and a summary of evidence to help build a case for investing in Healthy Universities
…questions and checklists to help you get started and move forward with planning, implementing and evaluating your work.
Consider whether your university is taking a whole system approach to health and wellbeing.
Use the planning cycle to reflect on your own situation – identifying entry points to get started or key priorities for moving forward.
Develop your arguments to help secure the buy-in and/or ongoing engagement and commitment of senior managers.
Identify a relevant committee or working group and tailor and present one of the template powerpoint presentations available on the Healthy Universities website (Getting Started, Making Links, Making the Case).
‘Systems thinking is a discipline for seeing wholes. It is a framework for seeing interrelationships rather than things, for seeing patterns of change rather than static ‘snapshots’.’
Senge P. (1990) The Fifth Discipline: The Art and Practice of the Learning Organization. London: Random
The whole system Healthy Universities approach:
Key concepts underpinning this whole system approach include:
The emphasis on viewing the university as a system can be usefully illustrated by mapping the links between topics, population groups and components, as illustrated in the powerpoint presentation Making the Links which can be found in the Resources section of this Guidance Package.
The Healthy Universities approach has its roots within the Ottawa Charter for Health Promotion, which was influential in shifting health promotion away from problem-oriented individual interventions and towards a more holistic socio-ecological as ‘salutogenesis’ or health creation. The Ottawa Charter still has global influence today. Describing health promotion as ‘the process of enabling people to increase control over, and to improve, their health’, it argues that health cannot be separated from other goals and highlights the inextricable links between people and their environment that constitute the basis for a socioecological approach to health. It goes on to suggest that a key aim of health promotion is to generate living and working conditions that are healthy, safe, stimulating, satisfying and enjoyable – and that ‘health is created and lived by people within the settings of their everyday life; where they learn, work, play and love.’
The Ottawa Charter sets out three key strategies – advocacy, mediation and enablement – and highlights five action areas (see Fig. 1)
Figure 1: The Ottawa Charter for Health Promotion
Using the themes from the Ottawa Charter as a structure for whole system thinking, a number of goals can be developed that are appropriate and relevant to Healthy Universities (see Fig. 2).
Figure 2: The Ottawa Charter’s Action Areas as a Framework for Healthy Universities
Source: © Doherty, 2010
‘Our societies are complex and interrelated. Health cannot be separated from other goals…Health promotion is the process of enabling people to increase control over, and to improve, their health.’
World Health Organization (1986) Ottawa Charter for Health Promotion. Geneva, Switzerland: WHO.
The rationale for the settings approach, of which Healthy Universities is an example (others include Healthy Schools, Healthy Promoting Hospitals, Healthy Prisons, Healthy Workplaces and Healthy Cities) is based on the realisation that health is largely determined outside of the so-called ‘health’ service – a point reinforced by Wanless (2004) in his report Securing Good Health for the Whole Population, in which he uses the term ‘National Sickness Service.’ It follows that effective health improvement requires investment in the social systems and places in which people spend their time and live their lives. Universities represent one important focus, as discussed under the University Context section of this guidance package – and evidence from other settings suggests the value of adopting a whole system approach (see under Evaluation and Impact).
The Marmot Review into health inequalities in England was published in 2010. It shows that there is a social gradient in health, characterised by dramatic differences between best-off and worst-off and a graded relationship between social circumstances and health: the higher one’s social position, the better one’s health is likely to be. The report, entitled ‘Fair Society, Healthy Lives’, argues that:
‘Inequalities are a matter of life and death, of health and sickness, of well-being and misery. The fact that in England today people in different social circumstances experience avoidable differences in health, well-being and length of life is, quite simply, unfair.’
Reflecting that, traditionally, government policies aimed at reducing inequalities have focused resources only on those most in need, it argues for a new approach called ‘proportionate universalism’ whereby actions are universal, but with a scale and intensity appropriate to the level of disadvantage. Central to the report’s approach is a commitment to create the conditions for people to take control of their own lives. This requires action on the wider determinants of health, which are described as the conditions in which people are born, grow, live, work and age. These can lead to health inequalities – the unfair and avoidable differences in health status that arise because of inequalities in society.
The health map below (Fig. 3), developed by Barton and Grant, shows the complex interrelationships between health, lifestyle and the physical, social and economic environments. People are at the core of the map, being surrounded by layers of influence that could theoretically be modified. The first of these is lifestyle, for example a person could decide to give up smoking. Beyond this, the map shows how the individual is situated in a community, a broader social world comprising social networks and social support that can affect an individual’s health – for example, the individual could be encouraged by their friends or conversely feel pressured to remain a smoker because everyone around them is smoking. As the health map radiates out, wider influences exist that impact on decisions to stop smoking – for example, the availability of services to support people who want to stop smoking, the cost of cigarettes and legislation banning smoking in work and public spaces. The map also illustrates how human health is intimately connected to the health of the wider environment and ecosystems – pointing to the importance of integrating health and sustainable development agendas, as explored further in a parallel Guidance Package on Connecting and Developing Synergy between Health and Sustainable Development Agendas.
Figure 3: A health map for the local human habitat
Source: Barton, H. and Grant, M. (2006) A health map for the local human habitat. Journal of the Royal Society for the Promotion of Health 126(6): 252-261
‘The complexity and interrelationships…make a compelling case for the futility of isolated initiatives. Focusing heavily on one element of the system is unlikely to successfully bring about the scale of change required.’
Butland et al (2007) Tackling Obesities: Future Choices – Project Report. London: Department of Innovation, Universities and Skills.
‘There is…widening recognition that a system-based [Healthy Universities] approach has significant added value – offering the potential to address health in a coherent and joined-up way and to forge connections to both health-related targets and core drivers within higher education.’
Dooris, M. and Doherty, S. (2009) National Research and Development Project on Healthy Universities: Final Report. Preston: Healthy Settings Development Unit, UCLan
The whole system Healthy Universities approach offers a number of benefits – it:
Source: Adapted from: Dooris, M. and Doherty, S. (2009) National Research and Development Project on Healthy Universities: Final Report. Preston: Healthy Settings Development Unit, UCLan.
While evaluative research into Healthy Universities is still lacking and an evidence base has not yet been fully developed, it is possible to draw on research from other settings programmes, such as Healthy Schools and Healthy Further Education. This provides promising evidence that whole school and whole college approaches are more likely to be effective than a class-room only (educational) approach – although more research is needed to help understand more fully how and why. Findings from key reviews are summarised on the right:
Stewart-Brown, S. (2006) What is the evidence on school health promotion in improving health or preventing disease and, specifically, what is the effectiveness of the health promoting schools approach? Copenhagen: WHO Regional Office for Europe.
Whilst this World Health Organization Health Evidence Network Report only found evidence to support some of the features characterising the Health Promoting Schools approach (due, in part at least, to the paucity of research in this area), it concluded that:
‘The school health promotion programmes that were effective in changing young people’s health or health-related behaviour were more likely to be complex, multifactorial and involve activity in more than one domain (curriculum, school environment and community). These are features of the health promoting schools approach, and to this extent these finding endorse such approaches. The findings of the synthesis also support intensive interventions of long duration. These were shown to be more likely to be effective than interventions of short duration and low intensity. This again reflects the health promoting schools approach, which is intensive and needs to be implemented over a long period of time.’
St Leger, L., Young, I., Blanchard, C. and Perry, M. (undated) Promoting Health in Schools: From Evidence to Action. Paris: IUHPE.
This document provides succinct evidence-informed arguments to support the need for school health promotion. Showing how individual health issues, such as healthy eating, substance misuse and mental health, relate to a holistic view of health and health promotion, it advocates for a whole school (Health Promoting Schools) approach to strategically plan and implement school health initiatives. The content includes brief evidence summaries relating to specific topics and to a whole school approach – suggesting that multifaceted approaches are more effective in achieving health and educational outcomes than classroom only or single intervention approaches, and that a whole-school approach, where there is coherence between the school’s policies and practices that promote social inclusion and commitment to education, actually facilitates improved learning outcomes, increases emotional wellbeing and reduces health risk behaviours.
Warwick, I., Statham, J. and Aggleton, P. (2008) Healthy and Health Promoting Colleges – Identifying an Evidence Base.London: Thomas Coram Research Unit, Institute of Education.
This report draws on evidence from the UK and other countries and concludes that:
‘While it is not possible to state with certainty that multi-component, whole-settings approaches are more successful in college and university settings than one-off activities, the evidence points in this direction.’
‘Many risk factors are interrelated and can be best tackled through comprehensive, integrated programmes in appropriate settings where people live, work and interact.’
Northern Ireland DHSSPS (2002) Investing for Health (Para. 15.1). Belfast: DHSSPS
With 169 higher education institutions (HEIs) and more than 2.3 million students and almost 365,000 staff [Universities UK (2008) Higher Education in Facts and Figures: Summer 2008], the UK higher education sector offers obvious potential for the promotion of health and wellbeing.
Whilst the healthy settings approach provides a conceptual framework that can be applied to a wide range of contexts, it is important to understand the particularities of the specific setting to which it is being applied. There are a number of features of higher education that provide opportunities for investing in and shaping Healthy Universities:
Source: Dooris, M. and Doherty, S. (2010) Healthy Universities: current activity and future directions – findings and reflections from a national-level qualitative research study. Global Health Promotion, 17(3): 6-16.
There is a clear challenge involved in introducing and integrating ‘health’ within institutions that do not have this as their central aim, are characterised by ‘initiative overload’, and are operating in an increasingly competitive marketplace within a particularly difficult economic context. It is, therefore, essential that Healthy Universities work is linked to the core business of an HEI and is seen as a mechanism for the delivery of strategic objectives in areas such as student recruitment, retention, experience and achievement; widening participation; staff performance and organisational productivity; and teaching, learning and research.
The Healthy Universities conceptual model (Fig. 4) highlights the centrality to the approach of whole system thinking – facilitating coherent and joined-up action within and across the three key focus areas (relating to the environment of the setting, the core business of the setting, and connections to the wider community). Understanding and applying a whole university approach is key in taking Healthy Universities work forward in a way that maximises resources, expertise and effectiveness.
Figure 4: Healthy Universities: A Simplified Model for Conceptualising and Applying the Healthy Settings Approach to Higher Education
Source: Dooris, M., (2010) Healthy Universities: An Introduction www.healthyuniversities.ac.uk
It is necessary to put in place clear operational planning, implementation and management mechanisms to ensure effective whole university delivery. One way of conceptualising these is via a cyclical process model, as shown in Fig. 5. This depicts the series of stages that an initiative may go through – including identification of entry points; securing senior-level commitment and establishing a steering group; appointing a dedicated co-ordinator; undertaking a stakeholder mapping, needs assessment and audit of what is already in place; agreeing priorities and establishing working groups; formulating action plans; delivery; monitoring, evaluation and performance review; and recognition and celebration.
Figure 5: Healthy Universities – Operational Planning, Implementation and Management
Source: Adapted from Doherty, S. and Dooris, M. (2006) The healthy settings approach: the growing interest within colleges and universities. Education and Health 24(3): 42-43.
The implementation of the Healthy University approach involves utilising a portfolio of methods and mechanisms whilst maintaining three ‘balancing acts’:
In many situations, it may feel ambitious and overwhelming to embark on Healthy Universities using the whole system approach described – and a process may unfold that at first seemsmore ‘ad-hoc’. Howeer, by drawing on the thinking and models discussed, it may be possible to harness these ‘sparks’ of good practice and begin to join them up into a more coherent and comprehensive way of working.
A number of powerpoint presentations – Getting Started, Making the Links and Making the Case – are available to facilitate HEIs generate discussion on Healthy Universities and help to develop a whole university approach.
A whole system approach necessitates the engagement and active involvement of all the different parts of the university. To enable this to happen, it will be important to put in place effective communication and consultation mechanisms and to invest time and energy in building and nurturing internal and external partnerships.
Universities are large and complex organisations – and working with thousands of staff and students (as well as external organisations) in a meaningful way is an on-going challenge. As such, organised approaches will often be required in order to facilitate networking and help to build good relationships and effective partnerships – bringing together faculties, schools, services, students’ unions, and external public, private, voluntary and community sector partners. The Healthy Universities model tends to use informal networking to engage and connect people across boundaries and harness their energy, enthusiasm and resources. However, alongside this, it engages with more formal institutional structures and processes in order to ensure alignment with strategic planning and organisational change.
Questions for consideration:
Evaluation is a key dimension of a Healthy Universities approach, helping to build evidence of effectiveness and develop understanding of what works and why. It is widely acknowledged that evaluation should be pluralistic, incorporating a focus on both process and impact, and action-focused, informing future policy and planning and contributing to the sharing of good practice (for further information, see the Evaluation Section of the website).
Whilst it is relatively straightforward to evaluate individual interventions and activities, it is much more challenging to evaluate the effectiveness and added value of a whole system approach. This is partly due to the availability of funding and to how the public health ‘evidence system’ is constructed, but it is also because it is much easier to focus on relatively small-scale projects and apply linear thinking than it is to engage with complexity and map and understand interrelationships, interactions and synergies.
Source: Dooris, M. (2005) Healthy settings: challenges to generating evidence of effectiveness. Health Promotion International 21 (1): 55-65.
Drawing on standards relating to a whole school approach set by the National Healthy Schools Programme, it is possible to construct a set of process criteria that provide a starting point for universities wanting to review and evaluate their whole university approach:
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Getting Started Powerpoint Presentation
Making the Links Powerpoint Presentation
Making the Case Powerpoint Presentation
Barton, H. and Grant, M. (2006) A health map for the local human habitat. Journal of the Royal Society for the Promotion of Health 126(6): 252-261
Butland et al (2007) Tackling Obesities: Future Choices – Project Report. London: Department of Innovation, Universities and Skills.
Dooris, M. (2005) Healthy settings: challenges to generating evidence of effectiveness. Health Promotion International 21 (1): 55-65.
Dooris, M. and Doherty, S. (2010) Healthy Universities: current activity and future directions – findings and reflections from a national-level qualitative research study. Global Health Promotion.
Dooris, M. and Doherty, S. (2009) National Research and Development Project on Healthy Universities: Final Report.Preston: Healthy Settings Development Unit, UCLan.
Doherty, S. and Dooris, M. (2006) The healthy settings approach: the growing interest within colleges and universities. Education and Health 24(3): 42-43.
Marmot M, Allen J, Goldblatt P, Boyce T, McNeish D, Grady M, Geddes I. Fair society, healthy lives: The Marmot Review. London: The Marmot Review
Northern Ireland DHSSPS (2002) Investing for Health. Belfast: DHSSPS.
Senge P. (1990) The Fifth Discipline: The Art and Practice of the Learning Organization. London: Random
Universities UK (2008) Higher Education in Facts and Figures: Summer 2008. London: UUK.
Wanless, D. (2004) Securing Good Health for the Whole Population. London: HMSO.
World Health Organization (1986) Ottawa Charter for Health Promotion. Geneva, Switzerland: WHO.