Primary Health Care (PHC) has remained a priority on the global health agenda since the Alma Ata meeting [1]. The year 2008 thus celebrated 30 years of PHC policy with two major reports, “The World Health Report 2008 - Primary Health Care Now More Than Ever”[2] and the report of the Commission on the Social Determinants of Health [3]. Both reaffirmed the relevance of PHC in terms of its vision and values in today’s world. However, the world has changed radically since 1978 and is now characterised by globalisation, urbanisation, rapid communication and an increasing gap between rich and poor. In the context of health and health care the world has seen a shift from major concerns about communicable diseases to chronic non-communicable diseases (NCDs) and thus from targeted single interventions to concerns about the environment, life style and behaviours of people; ideological changes as dictated by neoliberal economics and new public management, along with dominance of large monetary management institutions such as the International Monetary Fund (IMF) over the United Nations (UN) organizations; and a shift from medical professional monopoly on decisions and resource allocation to a much wider role for lay people [4]. Moreover, the poorest part of the world has experienced the emergence of resource requiring vertical health programmes such as national HIV/AIDS, TB and Malaria programmes and of wealthy philanthropic organizations with substantial influence on national public health agendas. This situation presents large challenges and demands serious rethinking about the PHC vision. The traditional model of PHC is no longer sustainable, requiring a revitalization that entails fundamental changes in how primary care is delivered and financed.
The Ottawa Charter for Health Promotion defines health promotion as the process of enabling people to increase control over, and to improve, their health [5]. It conceptualizes health promotion action as building healthy public policy; creating supportive environments; strengthening community actions; developing personal skills; reorienting health services (beyond its responsibility for providing clinical and curative services) and moving into the future (with caring, holism and ecology as central strategic elements). The Ottawa Charter further specifies that health promotion action “has to be facilitated in schools, homes, work places and community settings” because “health is created and lived by people within the settings of their everyday life; where they learn, work, play and love”. WHO defines a “setting” as a “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… A setting is also where people actively use and shape the environment and thus create or solve problems relating to health”[6]. Poland and colleagues [7] further argues that settings are both the medium and the product of human social interaction and thus more than simply locations in space-time. The setting approach thus emphasises the individual, social and structural dimensions of health promotion.
The WHO Global Strategy for Health for All by the year 2000 [8] together with the Ottawa Charter [5] provided important inspiration towards establishing the holistic and multifaceted approach embodied by Healthy Settings programmes, as well as towards the integration of health promotion and sustainable development [9]. The key principles of Healthy Settings include community participation, partnership, empowerment and equity. The Healthy Cities programme is probably the best-known example of a successful Healthy Settings programme. Initiated by WHO in 1986, Healthy Cities have spread rapidly across Europe and other parts of the world [10]. The successes of settings-based approaches have been validated through internal and external evaluation and experiences [9]. On this basis WHO argues that Healthy Settings remains a useful, dynamic method to integrate risk factors and address disease prevention aiming to improve overall quality of life.
Factors influencing our health and quality of life are numerous and have been categorised by Whitehead and Dahlgren [11] as 1) biological, physical and constitutional such as age and sex, 2) individual and lifestyle related, 3) social and network related, 4) related to living and working conditions, and 5) political, socioeconomic, cultural and environmental. In a world where most high and middle income countries are struggling with the prevention and control of NCDs and where low-income countries will barely overcome the challenges of infectious diseases before NCDs are emerging as development and prosperity rises (giving rise to the so-called double burden of disease), the need to rethink disease prevention and health promotion strategies is bigger than ever. NCDs are characterised by their chronic nature and this puts an excessive and long-term burden on national health systems and budgets across the spectrum of low, middle and high income countries [12]. Sustainable successes in the prevention of NCDs are mainly involving structural and regulatory interventions such as increased taxation (on tobacco, alcohol etc.) and restrictions in the amounts of additives to food products (e.g. salt, trans-fats etc.) [13]. Such interventions are often effective in reducing disease incidence but may suffer from being authoritarian and in conflict with consumer interests. It has also been argued that taxation affects the poorest hardest and may thus be socially inequitable [14]. It may therefore be more socially equitable and politically viable to strive towards affecting people’s attitudes, motivations and practices in efforts to influence healthy living. Our attitudes, motivations and practices are formed by influences from a variety of people (e.g. parents, friends, employers, colleagues, teachers and media professionals) and conveyed in a variety of settings (e.g. schools, homes, neighbourhoods, work places, clubs, social networks and media). Our lifestyles, life qualities and health are thus not isolated and independent phenomenon’s, which can be adjusted and modified based exclusively on personal desires and needs. Our lifestyles, life qualities and health are also products of our life circumstances, social interactions and attention paid to societal discourses and diverse natures of influences affecting our senses.
In concordance with the increased or renewed recognition of the importance of the principles of PHC, health promotion action, and the social determinants of health, we have, as a contribution to the promotion of healthy lifestyles, further developed the setting approach in an effort to harmonise it with contemporary realities (and complexities) of health promotion and public health action. The paper introduces a modified concept, the supersetting approach, building on the optimised use of diverse and valuable resources embedded in local community settings and on the strengths of social interaction and local ownership as drivers of change processes. Based on a presentation of an ongoing initiative addressing the prevention of diabetes and other lifestyle diseases in a Danish municipality the paper discusses the benefits and challenges of supporting local community partnerships using the supersetting approach.
The supersetting approach
The conceptual framework
Health should be promoted within the settings of people’s everyday life because this is where people engage in daily activities and this is where environmental, organizational and personal factors interact to affect health and well being [5]. This important recognition from the early days of PHC is the foundation upon which the setting approach rests. It is also the foundation upon which the supersetting approach rests. The supersetting approach is an intervention strategy whereby coordinated activities targeting a common overall goal such as improved health in a population group are carried out in a variety of different settings and involving a variety of different stakeholders within a local community. The supersetting approach is more than a multi-setting approach. The supersetting approach strives to attain synergistic effects from operations that are carried out in multiple settings either simultaneously or phased but always in a coordinated manner. Furthermore, the supersetting approach cannot be implemented as a top-down model by e.g. researchers or city planners, but demands the active participation of local stakeholders. This has the advantage of bringing several community resources into play while preventing antagonistic action by opposing forces. As an example, efforts to affect the smoking behaviour among adolescents may benefit from coordinated efforts at schools, social media, sports clubs and supermarkets, but also at the work places of their parents. Without such multi-setting interventions the smoking patterns or attitudes of the parents may be counterproductive to the efforts in other settings to prevent smoking among adolescents.
Interventions based on a supersetting approach are first and foremost characterised by being integrated, but also participatory, empowering, context-sensitive and knowledge-based.
Integration
Effective and sustainable development is supported by an integrated approach to action planning, implementation, monitoring and evaluation. Integration refers to the coordination and, if possible, co-implementation of activities that share features in relation to applied methods, targeted populations, timing, expected outcomes etc. It also refers to the assimilation of values, approaches, procedures and standards in established structures and cultures of organisations in the local community and larger society. Finally, integration refers to the cooperation of stakeholders with diverse backgrounds and professions but acknowledging the interrelatedness and inter-sectoral nature of challenges facing society in the 21st century. The purpose of integration is thus to contribute lasting organisational value to stakeholders while achieving synergy in their achievements. The process of integrating health promotion initiatives, which often involves a variety of professions, sectors and disciplines, is obviously difficult but may be optimised by the early establishment of long-term cross-cutting coordination groups for stakeholder representatives. Once common levels of understanding of each other’s values, norms and aspirations are reached, these groups may enjoy flexibility in trying and testing bold ideas that would be difficult within the framework of individual mother-organisations. Sustainable integration of health promotion action cannot be forced but depends on the establishment of such mutual respect, trust and understanding of the needs and benefits of working together, by giving and taking, in order to reach a common overall goal. The Adelaide Statement on Health in All Policies proposes a new form of governance where there is “joined-up leadership within governments, across sectors and between levels of government“ in efforts to improve health outcomes and advance human development, sustainability and equity [15]. In recognition of this notion, the supersetting approach argues for optimised effectiveness of health promotion action by integrating efforts in intersectoral partnerships involving a diversity of relevant sectors such as health, environment, education, politics and finance.
Participation
Attitudinal and behavioural change of ordinary people not only requires knowledge and insight to alternative ways of thinking and acting but also psychological adaptation to norms and recommendations for better ways of living. The process of acquiring new knowledge and adapting psychologically to new recommendations is fuelled by motivation, and motivation is stimulated by active involvement and participation, which create a feeling of ownership of change processes. The supersetting approach thus argues for a high degree of participation of beneficiaries (target groups) in developing, implementing, monitoring and evaluating health promotion initiatives to increase the likelihood of achieving sustainable attitudinal and behavioural change. Moreover, the supersetting approach argues for inclusiveness in terms of informing, involving, engaging and partnering with as many community stakeholders (i.e. institutions, organisations, associations and companies within the private sector, the public sector, political systems, academia, civil society and the media) as possible. This is because of the wide availability, in all communities, of resources that are relevant for health promotion action. Resources can be material or financial, or they can relate to the dedication of time, expertise or creative thinking by ordinary citizens or professionals alike.
Empowerment
The supersetting approach emphasises a sustainable development rationale embedded in empowerment principles. The supersetting approach argues for promoting attitudinal and behavioural change by establishing and facilitating respectful dialogue with people, and subsequently making opportunities and support available to them, on how to acquire relevant knowledge, skills and experience in a particular subject. Empowerment is being properly promoted when people succeed in optimising their ability to define and argue personal attitudes, values and goals, and to act and take responsibility thereafter in a proper balance between personal integrity, social norms and societal rules and regulations. This is obviously time-consuming. People may be (and most often are) aware of their own unhealthy lifestyle, and of personal measures that should be adopted to improve it, but may lack the motivation and/or competences to take action. The deeper causes behind de-motivation and in-competences are to be found in the social determinants of people and their everyday pressures, and these are not modifiable over night. The supersetting approach recognises that people’s attitudes and behaviours are deeply rooted in people’s social contexts and systems and that these take a very long time to modify. In recognition of these difficulties, proper supersetting initiatives are bringing people to the centre of long-term social development processes based on respectful dialogue, competence building opportunities and motivating action.
Context
The political, social, economic, environmental and cultural contexts in the local community or in society at large are important attributes affecting attitudinal and behavioural change potentials and processes of ordinary people. Contextual factors can either be conducive or disruptive for health promotion efforts and should therefore be understood and, if possible, accounted for in the planning and implementation of supersetting initiatives. These factors may relate to structural (e.g. regulatory, legislative or financial) circumstances affecting the opportunities of stakeholders such as schools or sports clubs to engage in health promotion actions. In most instances it is possible for health promotion initiatives to understand and document these contextual factors but not to influence them. However, when attempts to modify structural factors are successful, this may effectively stimulate behavioural change. Contextual factors may also relate to the circumstances of everyday life as perceived by beneficiaries (people or populations groups) targeted by health promotion activities. In this case, context may comprise very local level barriers and opportunities at the level of the household, classroom, or local community. Examples are the presence/absence of active citizens dedicated to social mobilization for healthy living, the presence/absence of policies and strategies for healthy eating and physical activity in schools and day-care institutions, and the presence/absence of physical spaces and environments in the local community, which are conducive for healthy living. Such contextual factors should be understood and addressed through direct interaction and dialogue with beneficiaries, by identifying what is relevant, interesting and realistic in their view, and by jointly planning and implementing agreed upon activities.
Knowledge-based interventions
The supersetting approach is knowledge-based. It applies and produces scientific knowledge of highest standard within the framework of any respected research tradition and scientific discipline of relevance to the subject, e.g. natural, medical, social and humanistic sciences. State-of-the-art knowledge and experience is extracted from the scientific literature and used to inform the design of interventions. Moreover, scientific knowledge is produced by monitoring and studying the qualities of change processes and by determining the effects of interventions. Complex interventions in local community settings do not follow simple linear cause-effect relationship. Evaluating such interventions is therefore a challenging process for which a theory-driven evaluation method such as “realist evaluation” is a useful alternative to randomized controlled trials. Action research (and related participatory research methodologies) is a process of inquiry of particular importance to the supersetting approach because it builds on the active involvement of target groups (beneficiaries) in designing interventions and in iteratively evaluating and adjusting them during the course of a supersetting initiative. Applying action research thus complements other supersetting principles of participation, empowerment and action competence. The intention is to make disciplines meet and interact, and, in crossing their conventional boundaries, generate new and innovative approaches, interventions and solutions as well as broadening the scope and nature of findings from studying their processes and outcomes. Returning to the above example, efforts to affect the smoking behaviour among adolescents may include pedagogical intervention, health education, (mass and social) media intervention, social mobilisation, structural and regulatory intervention etc. Each of these interventions may benefit from epidemiological and register-based knowledge about the magnitude of smoking among adolescents, from detailed understanding of barriers and opportunities to cessation of smoking through qualitative in-depth interviews or focus group discussions, from active engagement of adolescents in defining and implementing solutions through action research, and from a broader understanding of smoking-related knowledge, attitudes and practices of adolescents before, during and after interventions through quantitative questionnaire surveys. The supersetting approach thus argues for interdisciplinary initiatives and theory-driven evaluation methodology in order to optimise interventions and enrich the findings.
When applying all of the above-mentioned principles and involving all relevant stakeholders, the supersetting approach provides a useful conceptual framework for sustainable health promotion action (Figure 1). Its specific elements are not new but so is the way they are structured. The supersetting approach thus builds on the best features of the setting-approach and of participatory and ecological whole-systems approaches. However, as a supplement to the setting approach, the supersetting approach insists on bringing very different community stakeholders (professionals as well as ordinary citizens) together for jointly developing, planning, organizing and implementing integrated health promoting actions across settings and across the wide spectrum of political, economic, social, professional and environmental interests; and as a supplement to the ecological whole-systems approaches, the supersetting approach insist on empowering community stakeholders through structured participatory development and implementation processes respecting the challenges of every-day life circumstances and fostering local ownership, motivation, responsibility and competences to act for a common cause. Sustainable health impact originates from the combination of these important principles of the supersetting approach.
The process of organising a supersetting initiative
A supersetting initiative is broadly owned by all of its stakeholders. Everyone must have a say in terms of influencing content and direction of the initiative. This necessitates the formation of a comprehensive organisation structure for dialogue, decision-making, coordination and action between ordinary citizens (beneficiaries), civil society organisations, public authorities and their institutions, private sector corporations, and researchers.
There are two main pathways through which a supersetting initiative can evolve. In a top-down pathway, a central core of professional organisations, institutions and/or corporations get together in response to a certain challenge, demand or idea, and establishes a joint communication and coordination forum (e.g. a steering committee) in which major strategic decisions are taken. A number of sub-structures and work groups are subsequently established. These have different roles and functions related to planning, implementation, monitoring, evaluation and research, and are therefore represented by different stakeholders, some of which are ordinary citizens. Over time, as the initiative matures and more stakeholders get onboard, the aim (and challenge) is to maintain a certain degree of overall formal coordination of activities while securing a high degree of communication between the organisational units as well as a high degree of autonomy for all units to take meaningful decisions and to be able to act on them. In a bottom-up pathway, the need for change emerges from interaction and dialogue among beneficiaries such as parents, elders, youth or ordinary citizens as a whole. A more or less informal community forum is established to transform ideas into a coherent strategy and plan, and to mobilise internal and external resources for their implementation. The aim (and challenge) is to operate at a grass root level and reduce outside dominance while attracting sufficient attention and interest among public and/or private authorities and funders to be able to implement what is planned. It is difficult to imagine an effective and sustainable supersetting initiative without elements of both top-down and bottom-up characteristics. Commitment from public and private sector authorities is required because they grant permission to involve their organisations and institutions such as schools, kindergartens, museums and libraries in an initiative, and they represent more or less permanent organisational structures that are resistant to fluctuations in personal motivations and commitments of involved citizens or professionals. Similarly, commitment from citizens and other target groups is required because these are the people who can best, from both an ethical and a practical perspective, define the needs and visions for their community, secure relevance and legitimacy of an initiative, and foster local ownership, social responsibility and sustained motivation to take action. The deeper the gap between the interests of societal authorities and its citizens, between formal organisations and informal social movements, the more difficult it becomes to manage and implement a supersetting initiative. No matter which top-down and bottom-up balance is applied, a proper supersetting initiative must support bold ideas and risk-taking, acknowledge the diverse competences and functions of professional stakeholders, and fully respect and involve its beneficiaries, the prime target group of citizens, in order to succeed and bring about sustainable impact in health promotion.
The case: a Danish supersetting initiative
To illustrate the prospects and challenges of the supersetting approach, this section briefly presents an ongoing supersetting initiative with emphasis on how it was formed and how it complies with the values and principles of the supersetting approach. The initiative is called “Health and Local Community” and is carried out in three local communities in the Danish municipality of Bornholm, an island with a land mass of 588 square kilometres and a population size of approximately 42.000 inhabitants. Most health and social indicators of the population are below average for the country. “Health and Local Community” is a research and development initiative aiming at influencing the lifestyle habits of families with small children aged 3–8 years with emphasis on mobilising community resources, strengthening social networks, and promoting healthier food choices and more physical movement. Apart from the main target group of families with small children, the initiative involves several local stakeholders and settings, most notably professionals within primary schools, after-school centres, childcare centres, supermarkets, media and a number of civil society organisations and resource persons with expertise in nutrition, cooking, recreation and physical movement. The initiative also involves three Danish research institutions with various levels of expertise in public health, epidemiology, social science and education. “Health and Local Community” receives most of its funding from a private Danish charity foundation, the Nordea-fonden.
“Health and Local Community” has been designed to comply with the values and principles of a supersetting initiative. This is illustrated as follows:
Integration. The initiative implements coordinated and integrated interventions in local primary schools/childcare centres, supermarkets and media. This is done in a formal partnership between well-established organisations, institutions and private enterprises in the local community. The partnership includes three departments within local government (i.e. health/social services, education/day-care and leisure-time/prevention), a local NGO engaged in community development (and hosting the local coordinator of the initiative), three supermarket chains with outlets/shops in the targeted communities, and the local TV station. Furthermore, the initiative has established local action groups for professionals (e.g. school teachers, shop owners, fitness instructors etc.) and citizens working and/or living in the targeted communities. These local action groups serve as coordination and mobilisation forums for community arrangements that are identified, planned and implemented through voluntary engagement. The broad representation of participants in the local action groups allow for the implementation of activities that are truly community-based and community-involving rather than setting-specific. The formation of local action groups is therefore an important operational step, which will foster synergistic actions across settings and optimise their local relevance, integration and sustainability in line with the principles of the supersetting approach.
Participation. The development of interventions is based on the use of participatory methods involving local stakeholders, most importantly the prime target group of families with small children. Participation takes place at several levels and in different locations and situations. Although variation occurs, the tendency is that 1) evaluations and strategic planning are carried out at joint annual meetings involving high-level decision-makers, managers and in-charges of formalised partners, 2) six-months thematic planning involves managers, in-charges and professional employees of formalised partners, 3) activity planning and implementation involves local professionals, resource persons and citizens on a case-to-case basis. Moreover, participation either occurs around setting-specific arrangements implemented in places such as schools, kindergartens or supermarkets (and involving children, parents, grandparents, customers, professionals etc.) or around truly cross-cutting community arrangements organised by participants of the local actions groups. The researchers support these local processes by presenting ideas for inspiration of local stakeholders, by contributing scientific knowledge about relevant issues such as nutrition and physical movement, and by facilitating meetings and training courses according to locally defined needs.
Empowerment. The initiative supports empowerment processes through social learning and action-competence building [16]. The most important target group for empowerment processes in the initiative are children. By use of participatory learning methods such as future workshops [17] children are engaged in processes of identifying and solving problems in their local environment. We mainly use visionary representations in the form of photos, drawings, collages and physical models to stimulate reflection and expression of opportunities, visions and ideas that would make the local environment such as class room, canteen or outdoor physical space more attractive, interesting, fun and healthy to use. These are presented to wider audiences of relatives and professionals, and key priorities emerging from the processes are brought forward by the initiative and turned into concrete projects for implementation in and by the local community. Children thereby experience a connection between their own visions and expressions for a better physical and social environment, and subsequent responses and actions by adults. Whereas this builds action competence in children, the initiative also provides capacity and training to professionals to sustain these processes in iterative cycles of participatory engagement of children and adults, and joint evaluations and adjustment of actions.
Context. The initiative benefits from its wide network of local stakeholders, including its relationship to local mass media (TV, radio and newspapers), to monitor contextual factors that may influence the realisation of planned activities. These factors relate to community and societal developments and influences such as changes in local government priorities, structural adjustment plans, sector-specific budget changes, related development initiatives, mass media agendas, and weather conditions as well as very local developments and influences such as institutional planning cycles, staff changes, motivations of citizens, and local community events. The initiative constantly re-plans and re-organises according to changing circumstances, and actively uses contextual information to avoid clashes of interests and to engage in local events such as public meetings, debates and other arrangements.
The conceptual framework of “Health and Local Community” is outlined in Figure 2. A main feature of the conceptual framework is its high level of complexity, which is a result of the holistic nature of the initiative and the wide involvement of local stakeholders. Three main pathways of actions and outputs are apparent in the figure. One of these pathways illustrates actions and outputs within schools and child care centres. Here efforts seek to involve children, parents, grandparents and professionals in defining and implementing solutions that promote healthy living by reconstructing the physical and social space within the institutions and, more widely, within the local community. Another pathway illustrates actions and outputs within supermarkets. Here efforts seek to involve shop owners and staff as well as customers (mainly families with small children) in defining and implementing ways of restructuring the shops for the purpose of promoting sale of healthy commodities (such as whole grain products and vegetables) and discouraging sale of unhealthy commodities (such a sweets and soft drinks). The final pathway illustrates actions and outputs related to the involvement of media. Here efforts seeks to engage local radio, TV and newspapers to report from, and actively participate in, all kinds of activities organised by “Health and Local Community” including sports events, nature walks, cooking workshops, fishing trips etc. It is noted from the conceptual framework that the three pathways are connected by arrows. This indicates that activities are organised across the different settings. As an example, school children are invited to local supermarkets to prepare their own packed lunches based on a wealth of healthy food products made available by the shop owners. This provides opportunities for school teachers to teach about nutrition and healthy eating in an alternative and very conducive environment. It also provides inspiration to parents who acquire ideas for preparing more interesting and healthy lunches to their children. Supermarkets thus functions as new social learning platforms for the children outside the traditional classroom. As another example, childcare centres and nature guides organise nature walks for children and parents with a focus on edible resources within the local environment; this is followed by outdoor cooking using nature’s ingredients and, subsequently, treasure hunts in supermarkets for equivalent food products. Local media closely cover these activities and debate them with lay people and experts in thematic programmes on healthy living. It is also noted from the conceptual framework that expected outcomes and effects of all these actions tend to merge and are not associated with one particular pathway. This illustrates a high degree of coordination and planning for synergistic effects and common goals, which is an inherent element of a supersetting initiative.
The organisational structure of “Health and Local Community” is outlined in Figure 3. The initiative is organised as a formalised partnership with key stakeholders shown in the figure. Informal partners in civil society (i.e. NGO’s and independent professional resource persons) are not listed in the organisational structure. The various boxes represent partners, settings, coordination groups and an independent advisory committee. An executive committee functions as the engine of the initiative with responsibility for day-to-day planning and coordination. This committee is the only organisational unit, which includes members from both arms of the initiative, namely the development arm and the research arm. It is through the executive committee that development and research agendas are synchronised and more widely communicated within the organisation structure.
During the first one and a half years of the intervention phase numerous activities have been implemented in all of the involved community settings. Jointly identifying and organising these activities with local stakeholders required massive dialogue and matching of expectations. At the beginning, therefore, limited attention was paid to securing synergistic actions and coordination across settings and professions. This is now changing and the initiative is currently entering a phase of transition. The initiative has become well-known across the island. Trust has been established between partners. It has been widely recognised that stakeholders have many diverse agendas and motivations for joining the initiative, and that no single stakeholder can have all of its ambitions fulfilled. Public and private authorities have thus acknowledged their positions as partners rather than owners of the initiative. Professionals in schools, childcare centres and supermarkets have realised that the initiative not only consumes staff time but also contributes resources in the form of creative ideas and tangible assistance from local stakeholders, external resource persons and researchers alike. The prime target group of children, as well as most of their parents and grandparents, are very attentive towards the initiative and engage themselves in various ways, e.g. by participating in arrangements, defining and shaping arrangements, producing accessories for arrangements, evaluating arrangements, communicating arrangements etc.