This paper starts by briefly reviewing the history, theory and practice of the settings approach to promoting public health--highlighting its ecological perspective, its understanding of settings as dynamic open systems and its primary focus on whole system organization development and change. It goes on to outline perceived benefits and consider why, almost 20 years after the Ottawa Charter advocated the approach, there remains a relatively poorly developed evidence base of effectiveness. Identifying three key challenges--relating to the construction of the evidence base for health promotion, the diversity of conceptual understandings and real-life practice and the complexity of evaluating ecological whole system approaches--it suggests that these have resulted in an ongoing tendency to evaluate only discrete projects in settings, thus failing to capture the 'added value' of whole system working. It concludes by exploring the potential value of theory-based evaluation and identifying key issues that will need to be addressed in moving forward--funding evaluation within and across settings; ensuring links between evidence, policy and practice; and clarifying and articulating the theories that underpin the settings approach generically and inform the approach as applied within particular settings.

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Highlighting the need for holistic and sustainable health improvement, this paper starts by reviewing the origins, history and conceptualization of the settings approach to health promotion. It then takes stock of current practice both internationally and nationally, noting its continuing importance worldwide and its inconsistent profile and utilization across the four UK countries. It goes on to explore the applicability and future development of settings-based health promotion in relation to three key issues: inequalities and inclusion; place-shaping and systems-based responses to complex problems. Concluding that the settings approach remains highly relevant to 21st century public health, the paper calls on the new "Royal" to provide much-needed leadership, thereby placing settings-based health promotion firmly on the national agenda across the whole of the UK.

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The settings approach appreciates that health determinants operate in settings of everyday life. Whilst subject to conceptual development, we argue that the approach lacks a clear and coherent theoretical framework to steer policy, practice and research.Aims: To identify what theories and conceptual models have been used in relation to the implementation and evaluation of Healthy Universities.Methods: A scoping literature review was undertaken between 2010-2013, identifying 26 papers that met inclusion criteria.Findings: Seven theoretical perspectives or conceptual frameworks were identified: the Ottawa Charter; a socio-ecological approach (which implicitly drew on sociological theories concerning structure and agency); salutogenesis; systems thinking; whole system change; organisational development; and a framework proposed by Dooris. These were used to address interrelated questions on the nature of a setting, how health is created in a setting, why the settings approach is a useful means of promoting health, and how health promotion can be introduced into and embedded within a setting.Conclusion: Although distinctive, the example of Healthy Universities drew on common theoretical perspectives that have infused the settings discourse more generally. This engagement with theory was at times well-developed and at other times a passing reference. The paper concludes by pointing to other theories that offer value to healthy settings practice and research and by arguing that theorisation has a key role to play in understanding the complexity of settings and guiding the planning, implementation and evaluation of programmes.

The settings-based approach to health promotion The settings-based approach to health promotion has its roots in the World Health Organisation (WHO)``Health for All'' initiative (WHO, 1980, 1985, 1991, 1998a) and Ottawa Charter for Health Promotion (WHO, 1986). The latter, which drew on both``Health for All'' and the work of theorists concerned with the creation of positive health ± what Antonovsky (1987, 1996) has called``salutogenic'' research ± reflected a growing consensus that health is a socio-ecological product that can be developed most effectively and efficiently by investing outside of the healthcare sector. The Charter stated that: Health is created and lived by people within the settings of their everyday life; where they learn, work, play and love. Health is created by caring for oneself and others, by being able to take decisions and have control over one's life circumstances, and by ensuring that the society one lives in creates conditions that allow the attainment of health by all its members. With its five-fold focus on healthy public policy, the creation of environments supportive to health, strengthening community action, developing personal skills and reorienting health services, the Ottawa Charter served as a catalyst to shift health promotion away from problems (as characterised by particular behaviours or by specific at-risk groups) and towards environments and settings. This shift is also reflected in recent work on``investment for health'' (Levin and Ziglio, 1996; Ziglio et al., 2000), developed through the Verona Initiative (http://www.who.dk/verona/main.htm). The first and perhaps best known initiative that has been retrospectively labelled settingsbased health promotion is Healthy Cities. Initiated as a small WHO project in 1986, with the aim of taking the rhetoric of Health for All and the Ottawa Charter``off the shelves and into the streets of European cities'' (Ashton, 1988, p. 1232), Healthy Cities rapidly grew to become a major global movement for the new public health (Tsouros, 1991). Drawing on this``macrolevel'' experience, parallel initiatives were established during the late 1980s and early The author

Community participation and empowerment are core principles underpinning the Healthy Cities movement. By providing an overview of theory and presenting the relevant findings of evaluations, this article explores how cities in the WHO European Healthy Cities Network have integrated community participation and empowerment within their development. Reflecting the inclusion of public participation and empowerment within the designation criteria for project cities, the evaluation of Phase III in 2002 demonstrated that community participation continues to be a high priority in most project cities. One-third of cities regularly consulted with large parts of their populations and another third undertook occasional consultations. Nearly 80% of cities had mechanisms for community representatives to participate in decision-making; and more than two-thirds of cities had initiatives explicitly aimed at empowering local people. Subsequent research carried out during 2005 further highlighted the centrality of public participation to the Healthy Cities movement. It found that all project cities continued to support community involvement. Community participation is an essential part of the process of good local governance, and empowerment remains at the heart of effective health promotion. To be meaningful, these processes must be seen as fundamental values of Healthy Cities and so must be developed as an integral part of long-term strategic development.

Despite the absence of national or international steers, there is within England growing interest in the Healthy University approach. This article introduces Healthy Universities; reports on a qualitative study exploring the potential for a national programme contributing to health, well-being and sustainable development; and concludes with reflections and recommendations. The study used questionnaires and interviews with key informants from English higher education institutions and national stakeholder organizations. The findings confirmed that higher education offers significant potential to impact positively on the health and well-being of students, staff and wider communities through education, research, knowledge exchange and institutional practice. There was strong support for extending the healthy settings approach beyond schools and further education, through a National Healthy Higher Education Programme that provides a whole system Healthy University Framework. Informants argued that although there are important public health drivers, it will also be necessary to show how a Healthy Universities can help achieve core business objectives and contribute to related agendas such as sustainability. Two models were discussed: an accreditation scheme with externally assessed standardized achievement criteria; and a flexible and light-touch framework focusing on change-related processes and utilizing self-assessment. While highlighting the appeal of league tables, many informants feared that a top-down approach could backfire, generating resistance and resulting in minimal compliance. In contrast, the majority felt that a process-focused aspirational model would be more likely to win hearts and minds and facilitate system-level change. Key recommendations relate to national programme development, research and evaluation and international collaboration and networking.