Supportive environments for Health Workshop


 Supportive environments for health – state of the art in research 30 years later and in future

An introduction to the workshop

 By Bo J A Haglund and Per Tillgren

In the Ottawa Charter five core action areas for Health Promotioin were suggested whereof Creating Supportive Environments fo Health (SE) has been very influential in public health discussions since. In the Ottawa Charter [1]it was 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.” Thus, health is created in relation to supportive environments for health.

 Objectives of the workshop:

The aim of this workshop is twofold: first to present state of the art in research and discuss one of the basic concepts of Health Promotion, Supportive Environments for Health. Second, to share experiences of the participants and their research in the field. Some of the questions we will raise are: What impact has the concept of SE had in the public health resarch publications? How has the the concept SE been used in doctoral theses ? How has SE been researched by some of the participants? What are the future challenges for research in SE ?


The 3rd International Conference on Health Promotion in Sundsvall 1991 focused on supportive environments and in the Statement from the conference the concept was further developed. The concept SE is thus a strategic concept about creating environments for better health (make the healthy choices easy choices). It´s focus is on equity and it is setting based and enable possibilities for change. Further, it goes from the medical dimension to a broad environmental concept including social-, political-, economic-, cultural- and existential dimensions namely a paradigm shift from biomedicine to sustainable development. As a consequence the concept therefor has an impact on established routines of work, job roles, means and methods, as well as ownership in terms of needs and problems to be solved.

The uniqueness with the Sundsvall conference was that it was the first conference where the international movements of health and environment joined their efforts. The report of Bruntland commission “Our common future” was linked to the “Health for all” strategies. The outcomes from the Sundsvall conference became therefor a corner stone in “Agenda 21” of the environmental conference in Rio.

The Sundsvall conference was planned and implemented in common by the Nordic countries. It was build on the five action areas of the Ottawa Charter: build healthy public policy; create supportive environments; strengthen community action; develop personal skills; and to reorient health services. In the Sundsvall Conference the focus was on Creating Supportive Environments for Health and the aim was to find practical ways to realize this in order to solve political, economic and managerial problems hindering the creation of a supportive environment and sustainable development. Equity and sustainable development as a health issue was highlighted.

The immediate outcome of the conference includes both material from the planning procedures of the conference like Briefing books [2],3],[4],5],[6],7],[8],[9] and material as outcomes of the conference like the Sundsvall Statementv(10), a Conference Report [11]and a Handbook including some practical models for change and a number of stories[12],[13]. The Briefing books were produces by the Nordic countries related to the SPOSE model (Sundsvall Pyramide of Supportive Environments) of the SE concept presented in the Handbook. Norway on Food, Finland on Social support, Denmark on Housing, Sweden on work. Transport and the impact of SE for the “3rd world countries” were presented by WHO, Geneva. In order to share practical experiences as requested from rest of the world we used the narrative research tradition, telling stories. Stories have the advantage that they can be transformed to your own situation[14]. In the stories we raised questions on problems to solve, what kind of solutions used, and strategies used for change and achieved outcomes. In the Handbook two other models are important. First, the Health Promotion Strategy Analysis Model (HELPSAM) supporting the analysis of best ways of creating SE. Second, the SESAME model (The Supportive Environment Action Model). These models came out of the analysis of more than 1.500 stories sent to the conference by the participants.

Impact of SE in scientific articles and theses

 In order to get an overview of the impact of the concept and notions of Supportive environments for Health a search was made in spring 2016 in several data bases.

A search in Google Scholar using “Supportive environment for health” is presented in table I.

Table I. Number of articles by time periods including the concept “Supportive environments for health” using Google Scholar.

Time period Number of articles Comments
1980-1989 3 Grey material included
1990-1999 80
2000-2009 345
2010-2015 351

Out of the recent articles (2010-2015) 105 items were articles in English. 18 of those were from the journal Health Promotion Interntional. In the books 20 were doctoral theses, 9 master theses and 12 bachelor theses.

Within some of the recent key articles the relationship to concepts like sustainability and ecosystems are discussed as important[15]. It is also argued that a new type of Health Promotion education including sustainable health promotion is needed. A framework for evaluation of SE is presented by Dutch authors[16].

In searching for doctoral theses we used the phrase ”Supportive environments for health” to be found in abstract or text in several databases and found 6 doctoral theses from Sweden. One economic evaluation of public health programmes by Pia Johansson (Karolinska Institutet), two about school as setting for interventions by Maria Warne (Mid University) and Louise Persson (Karlstad University), and three about creating better environments for elderley by S Iversson, Gunilla Karlsson and Björn Slaug all from Lund University[17].

In addition another 3 Swedish theses were found using the phrase ”supportive environments” and ”health” in the abstract. Two consider the nature as an important environment for health by Palsdottir and Sahlin. One is about design of environments by Bengtsson[18].

If Ottawa Charter /Sundsvall and ”Supportive Environments” were used we got seven theses from Finland. Four of the theses are about Oral health by Cinar, Saied-Moallemi, Hiiri and Vysniauskaite. One is about healthy public policy comparing Finland and Portugal by Tervonen-Goncalves. One is about health promotion within primary health care by Cinar and Rappe has presented a thesis about the influence of green environment for elderly[19].

In Denmark we did not get any theses but recently a theme nuber of the Journal of Transdisciplinary Environmental Studies (TES) Volume 14, Number 2, 2015
on Health Promotion in a Sustainability Perspective[20].

We did not find any theses within the area of Supportive environments for health from Norway.

Hopefully, participants at the workshop can provide more examples.


SE has gained more and more attention in the healthy public policy documents. In Health 2020 for the Europe region with its 53 countries it is a major part[21]. Priority area 4 is Creating resilient communities and supportive environments[22]. It is stated in the document: “People’s health chances are closely linked to the conditions in which they are born, grow, work and age. Systematically assessing the health efects of a rapidly changing environment – especially related to technology, work, energy production and urbanization – is essential and must be followed by action to ensure positive benefits to health. Resilient communities respond proactively to new or adverse situations, prepare for economic, social and environmental change and deal better with crisis and hardship”. The Healthy Cities and Communities movement provides extensive examples on how to build such resilience, particularly by involving local people and generating community ownership of health issues. Other settings-based networks provide similar experiences – such as health-promoting schools or workplaces. Collaboration between the environmental and health sectors is crucial to protect human health. It is further stated: Countries have begun to develop policies that benefit both the health of the planet and the health of people and recognize that collaboration between sectors is crucial to protect human health from the risks of a hazardous or contaminated environment”. To share experiences with new stories on how to achieve sustainable health promotion is crucial.

Despite remarkable health gains, inequities persist between and within countries in the WHO European Region, and the Nordic countries are no exception. Actions to effectively tackle health inequities need to be carried out at all levels of government need to be told[23]. What role should we then have as health promotion researchers ? How to adopt the Marmot commision work and Health 2020 to the Nordic Communities at different levels[24]? What could be learned from the Malmoe commission work[25] ?

Finally, the 9th International conference on health promotion in Shanghai with its theme ”Health Promotion in the Sustainable Development Goals” has as its aim to reassert the significance of health promotion in improving health and health equity at the historical moment of 30 years anniversary of Ottawa Charter, and the first year of implementing the Sustainable Development Goals (SDGs) [26]. It will direct and guide Member States on the practical application of evidence-based health promotion concepts, approaches and mechanisms for achieving SDGs. What is our contribution for sustainable health promotion?

Organization of the workshop

The premise for the workshop is that participants share experiences and take part in other colleagues’ experience of the research field of SE in theory and practice. But the workshop is also intended for those who are interested to highlight SE in future research and PhD projects. The starting point will be an introductory review of the historic background and the basic elements of the SE concept. Followed by a literature review on how SE currently is applied in research and presented in doctoral theses. We hope to be enough participants for some group work. This workshop ends up with a general discussion on future challenges for the concept.


[1] Ottawa Charter

[2] Wilson DN, Thomas AM, Farrell JP, MacLean H, Tomic P. Creating Educational Environments Supportive of Health. Briefing Book to the Sundsvall Conference on Supportive Environments. Ottawa: Mininster of Supply and Services, Canada, 1991.

[3] Food and Agriculture. Briefing Book to the Sundsvall Conference on Supportive Environments. Oslo: The Norwegian Directorate for Health, 1991.

[4] Bistrup M-L. Housing and Community Environments. How they Support Health. Briefing Book to the Sundsvall Conference on Supportive Environments. Copenhagen: National Board of Health, Denmark, 1991.

[5] Social Support and Care. Briefing Book to the Sundsvall Conference on Supportive Environments. Helsinki: National Agency for Health and Welfare, Finland, 1991

[6] Transports, Environment & Health. Briefing folder to the Sundsvall Conference on Supportive Environments. Sundbyberg: Karolinska Institutet, Institutionen för Socialmedicin och internationell hälsa. 1991.

[7 Haglund BJA, Pettersson B, Tillgren P, Finer D. Work for Health? Briefing book to the Sundsvall Conference on Supportive Environments. Sundbyberg: Karolinska Institutet, Institutionen för Internationell hälsa och socialmedicin, 1991.

[8] Carlsson G, Lindroth P, Olsson J, Forsberg S, Wikström R, Åhlström E. Livets villkor – på väg mot en hållbara utveckling i Västernorrland. Sundsvall: Landstinget i Västernorrland, 1991.

[9] WHO. Health Promotion in Developing Countries. Briefing book to The Sundsvall Conference on Supportive Environments 1991. Geneva: WHO/HED/91.1, 1991

[10] WHO Sundsvall Statement  healthpromotion/conferences/sundsvall.pdf

[11] Pettersson B, Tillgren P, Finer D, Haglund BJA. Playing for time. Creating supportive environments for health. Report from the 3rd International Conference on Health Promotion, Sundsvall, Sweden, June 9-15 1991. Sundbyberg: Karolinska Institutet, Institutionen för Internationell hälsa och socialmedicin, 1992

[12]Haglund BJA, Pettersson B, Finer D, Tillgren P. The Sundsvall Handbook, ”We Can Do It!” From the 3rd International Conference on Health Promotion, Sundsvall, Sweden, June 9-15 1991. Sundbyberg: Karolinska Institutet, Institutionen för Internationell hälsa och socialmedicin, 1992

[13] Haglund BJA, Pettersson B, Finer D, Till- gren P. Creating supportive environments for health: stories from the Third International Conference on Health Promotion, Sundsvall, Sweden. Geneva: World Health Organiza- tion, 1996 ISBN92-4-156180-7 Record Num- ber19971412661

[14] Labonte R. Reflections on stories and story / Dialogue method in health research. International Journal of Social Research Mathodologies 2011;14: 153-63.

[15] Blake Poland, Mark Dooris,Randolf Haluza- Delay. Securing ‘supportive environments’ for health in the face of ecosystem collapse: meeting the triple threat with a sociology of creative transformation. Health Promotion In- ternational. 2011; 26: 202-15

[16] Annemarie Wagemakers , Lenneke Vaandra- ger, Maria A. Koelen , Hans Saan, Cees Leeuwis. Community health promotion: A framework to facilitate and evaluate supportive social environments for health. Evaluation and Program Planning 2010; 33: 428–35

[17] 1.1 Johansson, Pia (2009). Economic evaluation of public health programmes : Constraints and opportunities. Stockholm: Karolinska Institutet, Department of Public Health Science

1.2 Warne, Maria (2013). Där eleverna är Ett arenaperspektiv på skolan som en stödjande miljö för hälsa. Östersund: Mittuniversitetet

1.3 Carlsson, Gunilla (2002). Catching the Bus in Old Age – Methodological Aspects of Accessibility Assessments in Public Transport. Lund: Lunds universitet, Division of Occupational Therapy

1.4 Iwarsson, S. (1997). Functional Capacity And Physical Environmental Demand. Exploration of Factors Influencing Everyday Activity and Health in the Elderly Population. Lund University.

1.5 Slaug, Björn (2012).  Exploration and Development of Methodology for Accessibility Assessments: Based on the Notion of Person-Environment Fit

1.6 Persson, Louise (2016). Health Promotion in Schools Results of a Swedish Public Health Project Karlstad: Karlstad University.

[18] 2.1 Palsdottir, Anna Maria (2014). The role of nature in rehabilitation for individuals with stress-related mental disorders.

2.2 Sahlin, Eva (2014). To stress the importance of nature.

2.43Bengtsson, Anna (2015). From experiences of the outdoors to the design of healthcare environments.

[19] 3.1 Tervonen-Gonçalves, Leena (2013). International Ideas and National Agendas of Public Health Policy – the Cases of Finland and Portugal

3.2 Cinar, Ayse Basak (2008). Preadolescents and Their Mothers as Oral Health-Promoting Actors : Non-biologic Determinants of Oral Health among Turkish and Finnish Preadolescents

3.3 Simonsen, Nina (2013). Health promotion in local contexts and enabling factors : A study of primary healthcare personnel, local voluntary organizations and political decision makers

3.4 Saied-Moallemi, Zahra (2010) Oral Health among Iranian Preadolescents : A School-Based Health Education Intervention

3.5 Hiiri, Anne (2008). Community-wide Oral Health Promotion in the Pitkäranta District of Russian Karelia – a case study

3.6 Rappe, Erja (2005). The influence of a green environment and horticultural activities on the subjective well-being of the elderly living in long-term care

3.7 Vysniauskaite, Sonata (2009). Oral health behaviour, conditions and care among dentate elderly patients in Lithuania: preventive aspects


[21] WHO. Hälsa 2020. Ett policyramverk för sektorsövergripande insatser för hälsa och välbennande i WHO:s Europaregion. Folkhälsomyndigheten: Stockholm, 2015. http://www. Halsa-2020-Sektorsovergripande-policyram- verk-insatser-halsa-valbefinnande-15008.pdf

[22] Health 2020. A European policy framework supporting action across government and society for health and wellbeing.

(23) Tackling health inequities: from concepts to practice. The experience of Västra Götaland.

(24) A roadmap to implementing Health 2020 – the experience of San Marino

(25) Commission for a Socially Sustainable Malmö.ökommisionen_rapport_engelsk_web.pdf

(26)  9th Global Conference on Health Promotion, Shanghai 2016 . Health Promotion in the Sustainable Development Goals

Some background articles related to the issue of SE (in Swedish)

 Haglund BJA. Alma Ata – Ottawa – Adelaide – Sundsvall, steg mot ett hälsovänligare samhälle. AllmänMedicn 1988;10:117-8

Haglund BJA. Folkhälsoarbetets framtida forskningsfrågor. Socialmedicinsk tidskrift 1990; 67, Nr 5-6:301-10.

Haglund BJA. Folkhälsoarbete är förändringsarbete – från diagnos till åtgärder. Socialmedicinsk tidskrift 1990;67, Nr 5-6:222-5

Haglund BJA. Samhällsdiagnosens roll i preventivt arbete – en teoretisk ram. Socialmedicinsk tidskrift 1990; 67, Nr 5-6:226-33

Haglund BJA. Stödjande miljöer för hälsa – ett strategiskt begrepp för det hälsofrämjande arbetet. Socialmedicinsk tidkskrift år 1996; no 2-3, 91-9.

Haglund BJA. Hälsofrämjande arbete inför 21 århundradet. Socialmedicinsk tidskrift1998;75:79-81.

Haglund BJA, Tillgren P. Forskning i hälsofrämjande arbete – ett interventivt forskningsområde med syfte att bidra till större social rättvisa. Smt 2009;86:128-38.

Haglund BJA, Fosse E. Nordiska konferenser i hälsofrämjande forskning. Rapport från den 7th Nordic Health Promotion Conference (NHPRC), Vestfold University College 17-19 june, 2013. Smt 2013; 90:630-5.

Haglund BJA. Från Samhällsanalys till Samhällsinstser – Malmökommissionen visar vägen. Smt 2014; 91:415-8.

Haglund BJA. Vi behöver nya berättelser om hopp i klimatkrisen – tänka globalt men agera lokalt. smt 2015;92:542-4.

Haglund BJA. Lika aktuellt: 25 år sedan Sundsvallskonferensen om ”Att skapa stödjande miljöer för hälsa” smt 2016;93: 3-4.

Haglund BJA, Tillgren P. Från Ottawa Charter till Shanghai Statement – en 30 årig resa i hälsofrämjande arbete.Smt 2016;93:128-37.

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