Keywords

Introduction

In 2021, the European Training Consortium in Public Health and Health Promotion (ETC-PHHP) will celebrate the 30th anniversary of its summer school in Valencia, Spain. This is the founding place for the first summer school, which was organised by Concha Colomer, Spanish co-founder of ETC-PHHP. Since 1991, 782 participants from over 60 different countries across multidisciplinary disciplines have participated in these annual summer schools.

Today, the consortium consists of 13 higher education partners from across Europe: University of Zagreb (Croatia); University of Chester (UK); University of Bergen (Norway); Wageningen University (The Netherlands); University of Perugia (Italy); University of Girona (Spain); HAN University of Applied Sciences (the Netherlands); Norwegian University of Science & Technology NTNU (Norway); University of Cagliari (Italy); The University of Alicante (Spain); Nexus Institute (Germany); University of Lodz (Poland) and the Lebanese International University (Lebanon). Each year a different partner organises the summer school.

Today, the network consists of these 13 higher education partners and 725 alumni participants from over 50 different countries, representing a broad range of disciplines from across the fields of public health and health promotion.

ETC was first founded to advance health promotion capacity following the publication of the Ottawa Charter (WHO, 1986). It emerged as a leader in helping practitioners translate and implement the somewhat ethereal theoretical nature of the key concepts of health promotion into everyday practice.

The starting point for ETC is to view health as a resource for life and living . In the 1992 ETC course, Aaron Antonovsky presented his research on the salutogenic approach as a theoretical framework on how to promote health through resilience and flourishing as opposed to the avoidance or prevention of disease. Since then, the salutogenic approach has been a key element of the ETC summer schools not only as a theory but also as a way of thinking, which permeates the planning, facilitation and evaluation of the summer school.

Unique to the ETC programme is the fusion of professionals, who exchange ideas on the salutogenic model of health in a trusting, safe environment. The deeper learning occurs through the process of exploring, listening, reflecting and engaging in dialogue with other professionals (participants and tutors) from diverse social and cultural backgrounds. Moreover, the summer school offers participants insight and skills in being able to work across many different languages and cultures, to master the real demands of working collaboratively on salutogenic principles.

ETC aims to advance health promotion capacity at masters and doctoral level, and practitioners, with several years of experience in health promotion. This level of seniority provides for an experienced, high-level exchange of rich and culturally diverse experiences in health promotion. This chapter outlines how salutogenesis shapes our way of working in post-graduate education.

Competence Development

The first summer schools in the 1990s for academic and non-academic professionals were oriented to the introduction of the new public health and health promotion approach (Ashton & Seymour, 1988). At that time, the field of health promotion theory and research was in its infancy; the evidence base for health promotion practice was limited, so fundamental health promotion ideas for capacity building needed to be developed. The salutogenic perspective offered a useful and inspiring theory to stimulate discussions and created a vibrant atmosphere to which we often refer to as the ‘ETC spirit’.

In the 2000s, the field of health promotion had expanded rapidly, and much had been written about health promotion theory and practice. We realised that most participants had a rather solid understanding of health promotion and salutogenesis. However, they did not always apply this knowledge in their research, policy and practice. The content of the course was, therefore, adapted to reflect this. The process not only remained the same but also evolved: the emphasis shifted away from knowledge transfer to competence development; based on the principles that all learning elements should be (1) comprehensible, manageable and meaningful; (2) participatory and democratic so that students can influence the programme; (3) support learning and (4) co-creating knowledge.

The salutogenic environment created in the course facilitates learning by doing and experiencing for both participants and tutors. Participants of the summer schools get an opportunity to collaborate in an international context and together design international projects and programmes which are based on salutogenic principles.

Each summer school has an overall theme that is chosen by the host (see Table 7.1 with titles of all courses since 1991). Throughout the summer school, the focus is on creating a programme that fosters interaction and participation between participants and tutors. This lifelong learning experience is a key strength of ETC.

Table 7.1 Topics addressed in the summer schools (1991–2020)
Full size table

Based on the pedagogic principles of cooperative and interdisciplinary learning (Hernandez, 2002; Morse et al., 2007), we focus on student-centred participatory methods. Learning occurs through the process of (self-)exploring, listening, reflecting and engaging in dialogue with other professionals (participants and tutors) with broad and diverse social and cultural backgrounds. ETC-PHHP promotes an approach to facilitate learning that applies the salutogenic model of health to practice (ETC-PHHP Team 2016).

The Summer School Programme

The summer school is structured in two parts: a preparatory distance learning element and a 2-week residential summer school.

On average, 30 participants and 10 tutors are involved (a total group of 40 persons). The distance learning element was introduced in the 2000s. During this time, the distance learning element focused primarily on knowledge, knowledge application and critical appraisal. In the second decade with our shift towards competences, we started to integrate critical reflections of personal and professional experiences and perspectives linked to conceptual discussions and best practice analyses. The results of the distance-learning assignments are then discussed in small groups during the residential summer school to support the meaningfulness of this learning activity. A total of 8 European Credit Transfer and Accumulation System (ECTS) credits can be earned: 4 for the distance learning and 4 for the residential summer school.

Since 2011, the residential part starts with the ‘Concha Colomer Symposium ’, a local conference or seminar open to a broader audience of professionals and academics in the field of health promotion. Concher Colomer is one of the founders of ETC and was Director of the Valencian IVESP (Valencian Institute of Public Health Studies, currently known as the Valencian School of Public Health (EVES)). She passed away in April 2011. The annual symposium is a tribute to her contribution to ETC and the field of health promotion. It sets the scene for the 2-week residential summer school. The symposium provides international participants with the opportunity to connect with the local public health and health promotion experts, politicians and international guest speakers. The symposium consists of a few keynote lectures as well as open space sessions to discuss the summer school’s theme with public health and health promotion experts from the hosting country also .

The residential summer school programme is divided into morning and afternoon sessions. The mornings consist of plenaries and the afternoons of group work. In the plenary sessions, we give short lectures followed by activities that stimulate discussions and interaction to enable the integration of knowledge and experience of both tutors and participants.

Knowledge is understood as the result of a constant co-production of everybody involved. The afternoon sessions are dedicated to group work. Here, participants work collaboratively on an international project in heterogeneous groups. Group members differ in gender, age, home country and experience. The combination of learning activities enhances comprehensive learning, understanding and the development of core skills in health promotion practice.

At the end of the first week , a local field visit is organised to experience and discuss local health promotion projects in practice. In 2019, we, for instance, visited the town Torroella de Montgrí, which shared how they work with an asset-based approach and how they were experts in asset mapping.

Following the Principles of Health Promotion

One of the five principles of health promotion is to actively involve the population (Ashton & Seymour, 1988). For this reason, during the summer course, the voice of the participants is included in all the sessions, especially in country profile presentations and the photovoice session.

In the country profile presentations, the participants, grouped by countries, present the state of the art of health promotion in their countries and illustrate this with examples of their research or practice. This inductive approach starting with personal experiences leads students to general concepts, content and knowledge (Hofmeister, 2011). The discussion about these experiences during the face-to-face summer school with fellow students integrates this personal approach in a wider international and social context.

Since the 2015 summer course experience in the United Kingdom, the consortium decided to integrate the everyday life of the communities of the town, which hosts the summer school through a photovoice session. Photovoice is defined as ‘a process by which people can identify, represent and enhance their community through a specific photographic technique’ (Wang et al., 2000). Participants are asked to take a picture in the host city representing an asset which, according to them, promotes health. They also are asked to describe their perspectives or feelings about the picture in one sentence. This activity helps participants to see and observe similarities and differences between their community and that of another country using the lens of a health promoter. Usually, the pictures are presented in an exhibition for the local municipality or community as a gratitude for their hospitality. For the municipality, the results of the photovoice activity bring them international feedback on their local health promotion policies.

Another important goal of health promotion is to make it easier for people to make healthy choices. Several barriers, both within individuals and within their physical and social environment, can hamper the possibilities to make such healthy choices. This goal is not only facilitated by the host of the summer school offering healthy food, sports facilities and sustainable transport but also by participants who organise social activities such as walks after lunch, physical exercises during sessions or salsa classes to show some examples to facilitate healthful choices that can be applied in their home institutions. Also, the field visits usually provide examples in this respect.

Salutogenesis

Salutogenesis introduces two fundamental concepts: the general resistance resources (GRRs) and the sense of coherence (SOC) . GRRs are those resources that help a person or a system to avoid or to counteract a wide variety of stressors (Antonovsky, 1979; 1987). GRRs can be found not only within people as resources bound to their person and capacity but also within their immediate and distant environment, and can be both material and non-material (Lindström & Eriksson, 2010).

Health promotion professionals are expected to play an important role in helping people to learn how to recognise and use their GRRs and available SRRs to cope with stressors, and to strengthen their SOC (Super et al., 2015). This is central to the course, especially when some difficulties appear during the course, such as the feeling of time pressure to finish the group work or difficulties because of cultural differences in the way of working. The tutors and also the participants develop skills and abilities to talk about these difficulties and cope with challenges to mobilise the resources of the individuals or the group. These reflection processes strengthen the SOC of groups as well as of individuals.

If people can identify such resources in themselves or their immediate surroundings at their disposal, there is a better chance for them to deal successfully with the challenges of life. GRRs open up the possibility for people to construct coherent life experiences. More important than the resources themselves, however, is that the individual has developed the ability or capacity to recognise, use and re-use the resources for the intended purpose, which helps to improve health and well-being. A strong SOC facilitates this ability.

According to Lindström, the salutogenic model could become a lens for reading and co-constructing a learning/teaching process. Following this perspective, the course design is developed following the idea that students are active and participating subjects, who shape their lives and learning experiences through their SOC. As a consequence, a salutogenic learning model not only demands methods that support the acquisition of health promotion knowledge and competence but also other competencies in navigating lifelong learning, such as narrative skills, problem-solving, guidance and reorientation, self-assessment and the communication of emotions. In other words, learning experiences should balance previous experiences with what is learned and what could be shifted into future practice (Garista et al., 2019). This salutogenic course design privileges learning and teaching methods capable of giving voice to all aspects of human experience. Visual and expressive methods support the use of verbal techniques to balance cognition and embodied cognition in knowledge building, from team-building activities to participatory evaluation sessions. During the long story of ETC, several methods have been explored and then introduced into the course, showing all possible dimensions that could generate knowledge about health and quality of life : narratives, art performances, senso-biographic walking, drawings and cinema. All these methods become useful and make sense only within a meaningful relationship between tutors and students. A salutogenic approach for learning requires not only the general competencies of the tutors but also the co-creation with the participants (Eriksson, 2019). During the summer school, the synergies between all participants permit to create a collective sense of coherence. Participants, for example, present tools they work within their own country and discuss what the use of these tools in another context can mean. Taking into account the dimensions of SOC, it is possible to establish some parallels with the creation of this salutogenic ambiance of learning. Comprehensibility is related to a person’s capacity to transform stimuli into information about what is being experienced or perceived that is meaningful, orderly, consistent, structured and clear. The ETC summer school offers a participatory and transparent type of management, gives clear and detailed explanations of the programme and activities to the participants and looks for creative strategies to solve problems. Manageability refers to the individual’s perception of the available resources and their adequacy to meet daily demands. During the summer school, mutual trust between participants and tutors is key. There is a relaxed atmosphere that everything will be fine, and knowledge and resources contributed by each person are considered to support the course. However, the most fundamental idea is the thought that difficulties are not considered an individual problem but a collective opportunity that requires collective solutions. Meaningfulness indicates the extent to which a person feels that life makes sense emotionally and, despite the problems and difficulties, is sufficiently motivated to put effort into confronting them. The ETC consortium has a vision based on human rights and equity, which gives the overall activity a high level of meaningfulness. Personal involvement, strong motivation and team building create group synergy. Apart from a team-building session, the morning sessions include activities to increase the feeling of belonging.

While developing the programme for each summer school, including the distance learning element, we aim for a high level of coherence. Each element is discussed in its relevance for the overall theme and how it is connected to other parts of the programme so that the result is a comprehensible, manageable and meaningful narrative for participants, tutors and the hosting community.

Assets

Salutogenesis focuses on health rather than on disease. Morgan and Ziglio (2007) defined assets as any factor or resource that enhances the capacity of individuals, communities and populations to maintain health and well-being. It highlights the positive abilities of each person and their capacities to identify problems and enable solutions to increase self-esteem and leadership in individuals or communities (Morgan et al., 2010). The summer school has an asset orientation; that is to say, the course draws on all those assets provided by the host, the city, the participants and the tutors. Therefore, the first competence that the summer course aims to train is to be attentive to discover the assets of oneself and of other people from different communities, spaces and places. After this, the aim is to develop the competence of creativity to discover where this asset can fit for the benefit of the collective. For this reason, it is a dynamic and flexible course that can adapt to the interest, needs and assets of the members of it.

The assets of the participants are mobilised through a tools session, in which they present useful tools, the country profiles and the group work. Group work can be considered as ‘cooperative learning’ or ‘team learning’. It is about the creation of cooperative structures that are effective in promoting high-level thinking and learning in a group (Kennedy & Vaandrager, 2011). Effective group learning is based on the principles of using the power of the team to encourage students to accomplish the learning objectives (Hernandez, 2002). In all these activities, the participants use their assets, are empowered and discover other assets to mobilise them for the team effort. Simultaneously, these activities develop a sense of community and usually a collective asset mobilisation.

The assets of the hosts are also mobilised. The summer school is organised in a different place every year as each host has different assets to explore. These assets include the multiple and diverse connections to the locality, or regional structures and the stakeholders involved in the course but especially in the Concha Colomer Symposium and the field visit. The Concha Colomer Symposium includes a theoretical introduction of the summer school’s theme and, at the same time, some good practices of the host community. The field visit allows participants to observe how to apply the theme in reality and discover new visions or different ways of working with and for the community.

The competences, knowledge and skills of tutors and especially their experience are essential assets for the course. Their assets are shared during formal sessions or taking a coffee break in the canteen, or walking to the accommodation. Participants and tutors are equal, the course is transversal and this fact permits co-creation. This way of working and how things are addressed is appreciated by participants and the host institution, and facilitates salutogenic practice, research and policy.