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Setting Approach

Rolf Rosenbrock, Susanne Hartung

(last update 05 August 2015)

A setting is a social context in which people spend their everyday lives and which has an influence on their health.

This context is relatively permanent and its members are subjectively aware of it. It is expressed via formal organizations (e.g., businesses, school, nursery school), regional situations (e.g., municipalities, district, neighborhood), shared circumstance (e.g., retirement), shared values and preferences (e.g., religion, sexual orientation) or via a combination of these features.

Settings of interest from a health perspective are the ones from which important impulses or influences on the perception of health emanate on health stressors and/or health resources as well as on all forms of coping with health risks (balance between stresses and resources). Setting interventions are all the easier to organize, the more clearly the ‘membership’ is defined and the lower the fluctuation, the clearer the structures and rules and the better the formal and informal stakeholders can be integrated into the setting and its alteration with regard to planning and procedure. If important partners are not included, this could lead to failure. An open definition of the setting can have the same effect, if no clear and binding co-operative structures are developed. A setting thus always also denotes a demarcated social system that is defined for the purpose of a health-promotion intervention and in which the decisions and expert measures necessary for the concrete health-promotion measures are given.

The setting approach brings into focus the living environment of people and therefore the determining conditions under which people live, learn, work and consume. It is an answer to the limited success of traditional health-education activities, which address individuals with information and appeals. It accommodates the insight that health problems in a certain segment of the population are the result of a two-way relationship between economic, social and organizational factors and personal lifestyle. Settings are social systems and must therefore be distinguished from technical systems in the sense of ‘trivial machines’.

The formulation of a settings approach was a significant step for the advancement of health promotion. Several very well-known health-promotion programs, most of them initiated by the WHO, use it for orientation. The settings approach was confirmed as a central strategy in the WHO program ‘Health 21’. In Germany, the settings approach has so far seen its greatest distribution in company health promotion and also, increasingly, in educational institutions (universities, colleges, schools, nursery schools) and municipalities/districts/neighborhoods, where the experiences gathered are taken on board and developed further.

The acceptance of the settings approach is seen not least in its explicit mention in the Disease Prevention Law passed by the German Bundestag in July 2015, which strengthens health promotion and primary disease prevention in settings. The disease prevention guidelines of the German health funds’ umbrella organizations to implement SGB [German social legislation code] V, sections 20 and 20a also explicitly refer to the settings approach.

Generally speaking, primary disease prevention/health promotion can be carried out in two different but not completely unrelated ways in the setting: in primary disease prevention and health promotion in the settings approach, the accessibility of the target groups in the setting is used to deliver services of behavior-related prevention, e.g., with regard to the major risk factors  (nutrition, exercise, stress and drugs). One example of intervention within a setting is the provision of nutrition booklets at a parents’ evening in school. The spectrum of interventions ranges from the use of a setting to place information intended for a certain target group all the way to participatory programs designed especially for one or more groups in the setting. Generally speaking, the structures and processes in the setting remain unchanged in this approach and form the framework for the intervention.

Projects for the creation of a health promotion setting focus conceptually on the participation of the setting’s members and on the process of systematic organizational development. One example here is in-company health promotion with its instruments of staff surveys, employees’ meetings and especially ‘health circles’.

Creating health promoting settings with participation of the target groups and stakeholders that is as direct and enduring as possible relates to all four phases of the Public Health Action Cycle the definition and assessment of the problems to be dealt with, the design and determination of the intervention, the implementation of the intervention as well as the quality development and assurance.

Setting interventions of this type are complex and generally require professional qualifications in systemic organizational development  and participatory research. At the core is the idea that processes can be triggered in the setting by facilitating, initiating, supporting and accompanying intervention from the outside, with which users help shape the physical and social structures and stimuli of the setting according to their needs and are able to experience this influence subjectively (empowerment). Projects to develop a health-promoting setting constitute a kind of social reform movement for the particular setting; this movement is, however, mostly induced from the outside and therefore ‘synthetically’. Such setting projects also often include services to support behavioral modifications. The fundamental difference from similar or even the same behavioral interventions with the approach ‘health promotion in a setting’ is that such interventions, as part of a participatory process of making changes to the setting in terms of organization, social climate etc., are identified, requested and usually (co-)shaped by the users of the setting themselves, who then provide flanking for the participatory organizational development and in fact represent a component of it.

Table 1. Overview of established settings approaches in Germany, expanded and updated illustration based on Altgeld (2004).

Table 1. Overview of established settings approaches in Germany, expanded and updated illustration based on Altgeld (2004).

The (ideal) result would be for a health-promoting setting to make the process of organizational development an ongoing one, so that the decentralized renewal processes migrate or rotate through the different areas of the setting. That way, the setting ‘re-invents itself’ in participatory discourses in a continuous and piecemeal manner. The desired result is that the formal and informal, the material and the immaterial carrots and sticks will suggest, reward or support an increase in activation and social support as well as a reduction in physical and psycho-social health stressors. Thus, the idea is to effect changes which are good for the wellbeing and health of people in the setting.

With such interventions the close connection between behavioral disease prevention and structural disease prevention is not mere intention. Since the intervention relates to the entire setting, discrimination against sub-groups can be avoided. The settings approach also facilitates co-operation and communication beyond hierarchical and group boundaries. Health-related competencies are developed through increased transparency, participation and activation. In addition, the setting, better than all known approaches of behavioral disease prevention, fulfils the requirements for learning on the part of those with a low level of formal education: The information and activities tie in with everyday life and the existing resources, individuals can come together to develop their ideas about increasing resources and dismantling stressors, and this can be implemented as far as possible in a collaborative learning process. In addition, health successes in such setting interventions seem to remain relatively stable over several years at the least (sustainability).

Altgeld T, Expertise. Gesundheitsfördernde Settingansätze in benachteiligten städtischen Quartieren. Im Auftrag der Regiestelle des E&C der Stiftung SPI, 2004;
Baric L/Conrad G, Gesundheitsförderung in Settings, Gamburg 1999;
Freire P, Pädagogik der Unterdrückten, Stuttgart 1984;
Grossmann R/Scala K, Gesundheit durch Projekte fördern, Weinheim München 2001;
Rosenbrock R/Michel C, Primäre Prävention. Bausteine für eine systematische Gesundheitssicherung, Berlin 2007;
Trojan A/Legewie H, Nachhaltige Gesundheit und Entwicklung. Leitbilder, Politik und Praxis der Gestaltung gesundheitsförderlicher Lebens- und Umweltbedingungen, Frankfurt am Main 2001;
Wright MT (Hg.), Partizipative Qualitätsentwicklung, Bern 2010

Internet addresses:
www.gesunde-staedte-netzwerk.de (Gesunde Städte Netzwerk der Bundesrepublik Deutschland)
www.dnbgf.de (Deutsches Netzwerk für Betriebliche Gesundheitsförderung)
www.dngfk.de (Deutsches Netz Gesundheitsfördernder Krankenhäuser)
www.fgoe.org (Fonds Gesundes Österreich)

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