Health education addresses humans as individuals and groups. Health promotion intends to address humans as individuals and groups in the settings, in which they live, work, love and play. With the advent of the latest concept of health promotion, i.e. the Ottawa Charter, public health professionals shifted their language from an educational tone to a "community development" tone. They emphasized the importance of living conditions in relation to behavior, thereby implying that one has to work with the people in contexts in which they are enabled to lead "healthy lives".
Health promotion recognizes the idea that people live in social, cultural, political, economic, and environmental contexts. This acknowledgment may have been new for public health, however, sociologists and social psychologists have been aware of the embeddedness of behavior into larger contexts for a longer period of time. However, the acknowledgment by public health practitioners that health is developed in the context of everyday-life and which itself is structured by its related social system, has not led to a fundamental
reconsideration of the social science basis of public health concepts and its incorporation into planning and activity.
Individuals are still expected primarily to change their behavior despite the relevance that the public health discourse allocates to the socio-structural and cultural conditions of human life. Are we witness of newspeak regarding public health and health promotion?
In contrast to Leo Baric settings may be defined as spatial, temporal and cultural domains of face-to-face interaction in everyday-life. As far as health promotion is concerned, these domains seem to be crucial for the development of lifestyles and living conditions conducive to health. At least this is my interpretation of the term setting when analyzing policy papers of health promotion such as the Ottawa Charter (4), A call for action (5), and the final report of the Sundsvall Conference on Health Promotion (6).
Historically, the concept of settings played a major role in the development of ecological psychology. In this context they are defined as follows:
Rudolf Moos, who plays a prominent role in the development and application of the setting-concept summarizes its characteristics as follows:
Bronfenbrenner reviews sociological concepts of human development and concludes that they lack an understanding of the complexity of this development because of neglecting the frame of reference in which development takes place:
In six definitions, Bronfenbrenner outlines the basic ideas of his sociological approach to human development. Of particular interest for health promotion are the four different levels of the social system being of relevance to human development.
Human development, according to Bronfenbrenner, takes place in relation to four different layers of the social system, i.e. the microsystem, the mesosystem, the exosystem and finally, the macrosystem. He conceptualizes these layers as being interconnected on the one hand and as providing separate opportunities of social interaction being essential for human development. He configures human development to take place in specific socially, culturally, politically and economically defined environments that may be changing in the course of the developmental process. Change may occur within a given environment as well as with regard to movements from one environment to another (e.g., migration, social mobility, status change, etc.). The individual is recognized as a social human being connected to (significant) others and being able to shape her/his future according to her/his plans and, sometimes, despite hampering social and economic conditions. Influence on the developmental process is realized by the individual her-/himself, by her/his significant others, by agencies in relation to the specific environment and by changes of the environment itself.
On the next layer of the social system, additional features of social interaction are introduced which may go beyond face-to-face interaction.
Up till now Bronfenbrenner's conceptualization incorporated face-to-face interaction. The next layer of the social system Bronfenbrenner targets, is comprized of arenas of social power which exist despite or because of
communal face-to-face interaction. His definition of the exosystem refers to structural relations of power.
A macrosystem refers to consistencies, in the form and content of lower-order systems (micro-, meso- and exo-) that exist, or could exist, at the level of the subculture or the culture as a whole, along with any belief systems or ideology underlying such consistencies ...
The system's blueprints differ for various socioeconomic, ethnic, religious, and other subcultural groups, reflecting contrasting belief systems and lifestyles, which in turn help to perpetuate the ecological environments
specific to each group (16).
As a result of this conceptualization, Bronfenbrenner provides a new perspective on human development:
Two aspects are of importance here. A setting refers to:
A setting represents a frame of face-to-face, social interaction among human beings, the meaning of which is socially and culturally shared within the particular group of people being a part of the setting for a
certain period of time. That is, this particular meaning of the setting may vary among different social groups at different points in time, it may even be non-existent for other social groups at the same time.
If one talks about settings, one is talking about socially and culturally defined places of interaction which gain their meaning only with regard to those who subscribe to that definition and who interact in these settings.
Others may be able to understand the meanings of these settings, but they may also prefer not to become an active part in keeping the setting alive. Setting is a concept referring to interaction that takes place.
In this formulation, development and settings emerge as signposts for political measures - they are planned and negotiated, but by whom are these activities carried out and who has control over these measures in terms of public health policies in particular and as regards economic, environmental and other policies in general? The quotation indicates that action should be taken regarding certain domains of everyday life which are seen as being devisable like any other product. It takes living conditions and domains of social interaction as objects of planning and designed changed, thereby neglecting to recognize that these conditions and domains have been developed according to specific historical, economical, political, cultural, and perhaps spiritual frames of reference and will continue to do so. It does not refer to the participation or even co-determination of the people regarding their specific lifestyles and living conditions which determine their use of settings. In other words, it does not connect context (i.e. settings) with patterns (i.e. lifestyles), let alone that it does not connect patterns at all.
This is a mechanistic interpretation of Bateson's theory which does not take account of the fact that the development of "safe workplaces" or "socially supporting neighborhoods" cannot be designed by professionals and cannot be negotiated by political institutions displaced from everyday-life of the people they claim to take care of. On a different level of argumentation, it is a misunderstanding of the role of WHO when it claims to be able to improve individual and collective patterns of behavior in its member states.
It rather should draw its attention to the antagonisms of governmental policies as regards education, economy, health, social welfare and national development and it should feed back to its member states what it believes according to its knowledge goes wrong in their respective territories as regards the development of living conditions and lifestyles and their impact on health of their respected populations.
In public health and subsequently health promotion we have to be careful to define what we want to achieve with whom, when and where. Our activities are oriented to individual and collective well-being as outlined by WHO's definition of health. If we take the wording of physical, mental, and social well-being seriously, we have to come up with concepts related to where people interact face-to-face on a daily basis, and how we would be able to change either those structural conditions and/or their behavior.