Keywords

Introduction

Universities are important organisations for health promotion—not only as contexts and vehicles for enhancing well-being, but also as partners in multisectoral health improvement and as contributors to citizenship development and societal change (Dooris, Doherty, Cawood, & Powell, 2012). In the UK alone, there are 162 higher education institutions (HEIs) with almost 2.5 million students and more than 378,000 staff (HESA, 2013; Universities UK, 2013), pointing to the substantial global potential offered by universities as settings in which and through which to promote public health.

In exploring health promotion and salutogenesis in the context of higher education, it is valuable to understand the specific characteristics of the sector. For many years, universities have been the focus for the implementation of interventions on various key issues, leading to student-focused guidance on drugs, alcohol, mental health and other key themes (e.g. Crouch, Scarffe, & Davies, 2006; Grant, Kester, Donnelly, & Hale, 2002; Polymerou, 2007; Universities UK, 2000). These themes have tended to be constructed as ‘problems’ relating to risk-taking behaviour and ill-health, a focus mirrored by the traditional focus on reducing staff illness (e.g. stress).

While universities have historically been viewed as elitist organisations, there has within the UK and other countries been an increased concern over recent years to widen access and strengthen diversity, alongside the opening up of an increasingly competitive higher education ‘marketplace ’. For example, in England over the past 10 years there has been a policy of ‘widening participation’. The profile of students has become more diverse—with more mature students, part-time students and students from a wider range of socioeconomic backgrounds, many of whom are the first in their family to attend a university. These changes have coincided with and catalysed an increased focus on student engagement, experience and well-being, with universities recognising the importance of developing student support and well-being services to impact positively on retention and achievement .

In reviewing how health can be created and sustained in and through university settings, it is pertinent to reflect on the purpose of higher education. The Dearing Report (National Committee of Inquiry into Higher Education , 1997) identified this as fourfold:

  1. 1.

    To inspire and enable individuals to develop their capabilities to the highest potential levels throughout life, so that they grow intellectually, are well equipped for work, can contribute effectively to society and achieve personal fulfilment.

  2. 2.

    To increase knowledge and understanding for its own sake and to foster their application to the benefit of the economy and society.

  3. 3.

    To serve the needs of an adaptable, sustainable, knowledge-based economy at local, regional and national levels.

  4. 4.

    To play a major role in shaping democratic, civilised, inclusive society.

The role of higher education as an instrument of societal change has long been acknowledged—and Brennan, King, and Lebeau (2004) suggest that universities achieve this not only through producing highly skilled graduates and economically motivated research outputs, but also through helping to build new institutions of civil society and encouraging new cultural values. In the context of the ‘widening participation’ agenda, it has been argued that: “by encouraging students from all backgrounds to come to university, universities can do more than almost any other institution to improve social mobility and justice” (Schwartz, 2003), while the broader impact on local and regional communities is widely recognised in terms of employment, knowledge exchange, the built environment and social/community development (Centre for Urban and Regional Development Studies, 1994).

More recently, within the UK, this shift of focus has also been encouraged through a number of policy drivers. The Quality Assurance Agency for Higher Education (2012) has produced a quality code for student engagement emphasising the need for universities to provide an inclusive environment; the UK Government has produced a white paper ‘Students at the Heart of the System’ (Department for Business, Innovation and Skills (2011); and the Higher Education Academy has written a literature review on student engagement to facilitate the sharing of good practice (Trowler, 2010). Furthermore, the Higher Education Funding Council for England (HEFCE) (2014) is working with organisations to develop student engagement policies and inform practice as well as funding Student Engagement Partnerships.

These key developments have begun to encourage universities to gain more understanding of how health and well-being can be meaningfully translated and promoted within this setting. There is concern to provide appropriate advisory and therapeutic services that can respond to the range of health, social and welfare needs presented by this broadened student population. There is also a growing appreciation that universities comprise a range of ‘communities’ reflecting a broadened student population within which people can create their own social networks as well as being offered opportunities to engage, participate and become involved.

Moreover, salutogenesis implies a focus on health maintenance processes rather than disease processes. Antonovsky saw health-ease and dis-ease at two ends of a continuum. Salutogenic research looks at processes that move people towards, or keep people at, the health-ease pole.

Aligned to this idea, there have been signs of the higher education sector shifting away from a reductionist illness-oriented approach : this has been signalled by an increased use of the language of well-being and resilience (Marshall & Morris, 2011; Shutler-Jones, 2011; Steuer & Marcs, 2008) and a growing interest in moving beyond single topics and population sub-groups to embrace a more strategic and comprehensive ‘whole university’ approach that embraces students, employees and the wider community (Dooris & Doherty, 2009; Orme & Dooris, 2010). Universities and Students’ Unions need to be actively encouraged to work collaboratively to create these opportunities and develop appropriate services.

This approach endorses the Ottawa Charter (1986) in its assertion that “Health is created and lived by people within the settings of their everyday life; where they learn, work, play and love” and is located within the field of settings-based health promotion , which Kickbusch (1996) has argued strongly is salutogenic in focus—“shifting the focus from the deficit model of disease to the health potentials inherent in the social and institutional settings of everyday life”.

However, importantly, it is customised to the higher education context in recognition that universities have their own distinctive ethos and culture. Dooris et al. (2012) have proposed that this whole system perspective needs to consider the multiple roles of universities—as centres of learning and development; as foci for creativity and innovation; as places where students undergo life transition and where citizenship is developed via future shaping of students and staff; as workplaces and businesses; and as resources for and influential partners within local, regional, national and global communities.

This growing commitment to embedding health and well-being within the mainstream business of higher education coupled with the expectation that higher education will act sustainably in all that it does (HEFCE, 2014) provides the perfect springboard to also influence a process of co-ordinated action to develop sustainable, low-carbon campuses which can be considered to be salutogenic (Orme & Barna, 2010). The concept of sustainable development embraces environmental, social and economic dimensions and aspires to health-enhancing communities, societies and environments. This highlights the inextricable link between health and sustainability. This together with the growing commitment of universities to become more sustainable and to drive global change emphasises the strong link to salutogenesis.

The UK Healthy Universities Network suggests that the Healthy Universities approach aspires ‘to create a learning environment and organisational culture that enhances the health, wellbeing and sustainability of its community and enables people to achieve their full potential’ (http://www.healthyuniversities.ac.uk). In creating such healthy communities, we are defining communities not just by the absence of disease but how well people in them thrive.

This vision is likewise rooted in the settings approach and, while not explicit in its use of salutogenic terminology, can be readily understood to address the question ‘how can movement toward the health pole of the health-ease/dis-ease continuum be facilitated?’ A focus on human flourishing in the university context inevitably highlights those factors that enable people to make sense of their lives—what Antonovsky calls ‘general resistance resources’—and is concerned people experiencing a strong ‘sense of coherence’, which Antonovsky (1987) suggested predicted positive health outcomes.

A ‘sense of coherence ’ is a global orientation that expresses the extent to which one has a pervasive, enduring feeling of confidence that: the stimuli deriving from one’s internal and external environments in the course of living are structured, predictable and explicable (comprehensibility); the resources are available to one to meet the demands posed by these stimuli (manageability); and these demands are challenges, worthy of investment and engagement (meaningfulness).

Interpreted in this way, by creating a sense of community and a learning environment and organisational culture in universities, a healthy university approach plays a central part in enhancing or developing a strong ‘sense of coherence’ in their students and staff.

Research

As large organisations within which people learn, work, interact and live, universities inevitably impact on the health of their communities—with institutional policy and practice, management styles, communication systems, decision-making processes and service design and provision all influencing well-being and quality of life (Abercrombie, Gatrell, & Thomas, 1998). A focus on employee health has been strongly linked to performance and productivity, with the suggestion that universities need healthy and well-motivated workers if they are to deliver high-quality services (Health and Safety Executive, 2006, p. 1). While services play an important role, there is also evidence that social networks influence a range of psychosocial factors important to well-being which can be grouped into inter-related categories—such as ‘psychosocial effects ’ (felt social support/cohesion and sense of belonging), ‘collective efficacy’ (informal support and collective action) and ‘cultural norms’ (Harrop, Addis, Elliott, & Williams, 2006). There is also evidence that strong community networks can foster cultural norms which contribute positively to development and health behaviours (Harrop et al., 2006). In higher education settings with students maturing and growing in confidence through their experience in these communities, the importance of cultural change cannot be underestimated.

There are a number of research papers that explore salutogenesis, in particular individual-level sense of coherence, and its relationship to stress and mental well-being in university staff (Bezuidenhout & Cilliers, 2011; Kinman, 2008)—and other that focus on students’ sense of coherence and its relationship to both physical and/or mental health (Anderson Darling, McWey, Howard, & Olmstead, 2007; Kuuppelomäki & Utriainen, 2003; von Bothmer & Fridlund, 2003). However, while these provide insights into the experiences of staff and students at universities, they are not directly related to the concept of the ‘Healthy University’ and neither engage with nor reflect an understanding of ecological whole system thinking.

There is thus only limited research exploring the links between salutogenesis and the application of the healthy settings approach within the university context. Heiman (2004) reports on a study conducted in Israel, exploring the concept of the sense of coherence in relation to social support, coping styles and the stress experiences of university students.

While not contextualising the research within a healthy settings framework, she concludes that it would be valuable to focus on students and their interaction with the environment, using the concepts of stress, coping and social support as inseparable characteristics of a systems model. Graeser (2011), explicitly locating her research to settings-related theory , developed a University Sense of Coherence scale (combining the sub-components of comprehensibility, manageability and meaningfulness) and conducted two studies with employees at a German university.

The findings showed clear correlations between the organisational-level setting-based Sense of Coherence and health. Reflecting on these findings, she argues that cultural dimensions are the basis for an organisation-based Sense of Coherence, which plays a valuable role in shifting the focus from the individual to the organisation. She concludes that an organisation-based sense of coherence works in a dynamic way with individuals in that community. This research links well with the whole system perspective of Healthy Universities, acknowledging the importance of a university’s ethos and culture and discussing how individuals interact with and feel part of it—in this instance leading to learning around conditions conducive to mental health across an organisation.

Interventions and Empirical Studies

Dooris (1998, 1999, 2001) draws on the early experience of developing and implementing the University of Central Lancashire’s Health Promoting University initiative to describe and discuss the framing of a whole system approach and the successes and challenges. The work explicitly seeks to apply a settings approach, which is clearly rooted in salutogenic theory (Kickbusch, 1996). His ‘social ecosystem’ model (Dooris, 2001) identified inputs, processes and outputs and illustrated how Healthy Universities offers a means of investing in the health and well-being of students and staff. It is argued that this can be done by balancing a traditional pathogenic focus on addressing health needs and problems with a salutogenic focus on harnessing a university’s strengths, assets and potentials in order to support the well-being and flourishing of students, staff and the wider community.

More recently, this systems-based approach has been explored further (Dooris, 2005): it highlights opportunities for universities to increase understanding of health, well-being and sustainability and of their underpinning social, political, economic, cultural and environmental determinants; and it illustrates how universities play a key role in shaping the development of knowledge, values and priorities amongst students and staff—and how they have the power to shape their current and future influence within, outside and beyond the university.

Antonovsky (1996) asked what can a community do to strengthen a ‘sense of coherence’, that is comprehensibility, manageability and meaningfulness? The UK Healthy Universities Network has subsequently agreed a model to elucidate its vision which aligns with Antonovsky’s idea of a sense of coherence (see Fig. 23.1), that is a way of making sense of the world and a major factor in determining how well a person manages stress and stays healthy. Dealing particularly with the concept of meaningfulness, which Antonovsky believes to be the most important, Fig. 23.1 can help to generate a sense of meaning around a healthy university for staff, students and wider communities which helps to explain the important components in predicting positive health outcomes.

Fig. 23.1
figure 1

Healthy Universities—A model for conceptualising and applying the healthy settings approach to higher education. Source: Dooris et al. (2010)

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The model is underpinned by health promotion principles such as equity, partnership, participation, empowerment and holism (Rootman et al., 2001). Central to it is a whole university approach, which involves working within and across three key strategic areas of activity—with the aims of:

  • Creating healthy and sustainable learning, working and living environments (e.g. campus and building design, work–life balance policy and supportive management culture).

  • Integrating health and sustainability within the mainstream activities of the university (e.g. health as multidisciplinary cross-cutting themes in curricula, research and knowledge exchange).

  • Contributing to the health, well-being and sustainability of local, regional, national and global communities (e.g. health and sustainability impact assessment, locally embedded research, volunteering and outreach).

As further illustrated in Fig. 23.2, a whole university approach is also understood to be underpinned by health promotion values and to involve:

Fig. 23.2
figure 2

Healthy Universities—A whole system approach . Adapted from Dooris (2004, 2009)

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  • Anticipating and responding to higher education and public health drivers.

  • Securing ‘top–down’ leadership while also engaging ‘bottom–up’ stakeholder engagement and participation.

  • Combining long-term organisation development and change with high-visibility project work.

  • Balancing a pathogenic focus on addressing needs and problems with a salutogenic focus on harnessing a university’s strengths, assets and potentials in order to support the well-being and flourishing of students, staff and the wider community.

If practised in this ‘whole system’ way, the Healthy Universities approach offers opportunities to deliver important contributions to health, well-being and overall business performance and productivity . While there are no universally agreed indicators of impact, changes would be anticipated across a range of organisational functions (e.g. higher quality health and welfare services; healthy and sustainable food procurement processes and catering services; increased personal responsibility for health among students and staff and strengthened institution-level commitment to practise corporate social and environmental responsibility).

The information above is indicative of the well-developed literature around settings based approaches to public health that it is important to draw upon in any evaluation of such innovative work being undertaken in universities. Specifically, Healthy Universities can promote health and sustainability in an integrated and coherent way, and facilitate synergy between public health, sustainability and climate change agendas—taking steps to integrate its commitment by sharing examples of good practice in key areas such as active travel, sustainable food and curriculum design (Orme & Dooris, 2010).

Furthermore, Healthy Universities can make an important contribution to intersectoral health promotion through sensitising students (and staff) across multiple disciplines to a range of health issues and ‘future shape’ them as they clarify values, grow intellectually and develop capabilities that can enhance current and future citizenship within families, communities, workplaces and society as a whole (Dooris, Cawood, Doherty, & Powell, 2010).

In 1995, the Faculty of Public Health Medicine (1995) published a special issue of its newsletter, which argued that “initiatives in universities have emerged more or less in parallel with projects on the health-promoting workplace, school and hospital, but—without the benefit of any national or international infrastructure—they are only just beginning to generate a momentum of research and development” (Beattie, 1995, p. 2). Around the same time, two English universities—Lancaster and Central Lancashire—established Health Promoting University programmes and collaborated with WHO Europe in writing the first guidance publication on Health Promoting Universities (Tsouros, Dowding, Thompson and Dooris, 1998). In parallel, a German Working Group was established in 1995, evolving into the German Network of Health Promoting Universities (Stock, Milz, & Meier, 2010).

Academic literature focused on Healthy Universities has largely described project delivery or reported on specific research studies relating to particular aspects of health promotion practice—as summarised below. While much of this has been framed within the conceptual context discussed above, none of the publications report on research or programme implementation that has explicitly used salutogenesis or its component constructs as a framework.

Dooris (1998, 2001) reports on an evaluation of the first 2 years of the University of Central Lancashire’s Healthy University initiative, concluding that there is value in locating health promotion interventions within a holistic framework which considers the university setting as an organisational whole and appreciates that it is influenced by broader contexts and determinants . This is echoed in a Royal College of Psychiatrists (2011) report on the mental health of students, which states:

The ‘Healthy Universities’ initiative has adopted an ambitious rationale in relation to student health. The university or college is seen not only as a place of education but also as a resource for promoting health and well-being in students, staff and the wider community … The ‘Healthy Universities’ systemic and holistic approach is commended and should be adopted as widely as possible.

Xiangyang et al. (2003) report on the development of health promoting universities across Beijing, acknowledging the importance of a shift in focus from treating illness to prevention and health promotion and highlighting the centrality of creating health-supportive environments , and concluding that the university community can benefit greatly from implementing health promotion campaigns based on the principles of the Ottawa Charter.

Meier, Stock, and Krämer (2006) discuss the contribution of health discussion groups to health promotion at the University of Bielefeld, concluding that they offer a valuable means of increasing students’ participation and empowerment and of influencing strategic decision making.

An earlier study at the same university examined students’ health-related behaviours (Stock, Wille, & Krämer, 2001) and while framed in terms of ‘health needs’, highlights the importance of also focusing on health potentials and personal resources. Coffey and Coufopoulos (2010) report on students undertaking a health needs assessment at Liverpool Hope University. While the focus on needs would seem to locate the work outside of salutogenesis, the approach reflects a belief that a health promotion curriculum should itself enable people to increase control over and improve their health.

Reporting on a 2-year feasibility project concerned with the establishment of University of Brighton as a Health Promoting University, Davies and Hall (2011) highlight the connections with core agendas such as recruitment, retention and productivity and suggest that the process can be a valuable mechanism for harnessing and adding value to existing good practice. Emphasising the importance of applying Ottawa Charter principles such as building healthy policy and creating supportive environments, the report explicitly references salutogenesis. Similarly, in exploring the application of a whole system approach to food within the university context, Doherty, Cawood, and Dooris (2011) locate their discussion within the Healthy Universities framework, which they argue has an explicitly salutogenic orientation. Most recently, Knight and La Placa (2013) report on a pilot Healthy University initiative at Greenwich University. Using a settings approach that sees the organisation as a key determinant of its members’ health and well-being, this has prioritised the allocation of resources to activities that will create sustainable health-enhancing processes.

Discussion

When considering the implications for salutogenesis policy, practice and research relating to the university setting, it is valuable to explore developments and opportunities at three levels.

Firstly, at international and national levels, the interest in the whole system Healthy universities approach clearly reflects the success of other settings programmes such as Healthy Schools and Healthy Further Education. School-focused evidence reviews support a whole school approach, suggesting that effective programmes are likely to be complex, multifactorial and involve activity in more than one domain (Stewart-Brown, 2006; St Leger, Young, Blanchard, & Perry, 2010) while a review focused on further education concluded that “while it is not possible to state with certainty that multi-component, whole-settings approaches are more successful in college and university settings than one-off activities, the evidence points in this direction” (Warwick, Statham, & Aggleton, 2008: 27).

These conclusions resonate with wider research such as the Foresight Report on Obesity, which suggested that “the complexity and interrelationships …make a compelling case for the futility of isolated initiatives” (Butland et al., 2007, p. 10).

Reflecting this growing interest, overarching visions and frameworks have been proposed within which to structure work. The Edmonton Charter for Health Promoting Universities (2005) set out a shared vision that included enabling purposeful lives and creating healthy and sustainable environments, while the ‘Quality Criteria for Health Promoting Universities ’ issued by the German Network of Health Promoting Universities (2010) state that “A Health Promoting University is based on the concept of salutogenesis and focuses on the conditions and resources necessary for health”. As highlighted above, the UK Healthy Universities Network (http://www.healthyuniversities.ac.uk) positions a Healthy University as one that ‘enhances the health, wellbeing and sustainability of its community and enables people to achieve their full potential’—an aspiration that has been endorsed by the emergent European Network of Health Promoting Universities (http://www.eurohpu.aau.dk).

The UK Network has also produced a toolkit (http://www.healthyuniversities.ac.uk/toolkit) comprising guidance documents, case studies and a self-review tool, to support the evidence-informed delivery of a whole university approach to health and well-being that, while not necessarily using the explicit language of salutogenesis, is evidently salutogenic in orientation—encouraging member universities to foster health potentials and resources to support well-being and human development.

This toolkit facilitates universities to develop a proactive and coherent Healthy Universities action plan that strengthens resources and potentials and addresses a range of influences on the health and well-being of its community—through policy implementation, training, information, service provision, asset-mapping and skills development. Most recently, the Okanagan Charter for Health Promoting Universities and Colleges (2015) calls on higher education use a salutogenic approach to generate thriving, empowered, connected and resilient campus communities supported by a culture of well-being.

Secondly, at the university level, there is evidence of a growing interest in implementing such a whole university approach—encompassing a concern to ensure promotive and protective factors for health, well-being and human flourishing. In the UK, for example universities have responded to the student engagement and experience agendas by using student charters to express their intentions towards creating a learning culture and supporting students to reach their potential (Department for Business, Innovation and Skills, 2011); and university-based students’ unions offer a range of student-led clubs and societies across a range of interests and activities; and there are numerous examples of practical approaches to promoting an inclusive and valuing environment, developing appropriate services for staff and students and increasing access to affordable healthy and sustainable food. In guiding practice and research within an often large and complex setting such as a university, it is important to consider a number of connected questions: what are the likely mediators of these community effects? How can staff and students be supported to develop their sense of belonging? how can the institution as a whole provide a supportive context that can strengthen sense of sense of place and sense of self (Kickbusch, 1996)?

The third level to be considered is the interface between people within the university and the university as a context. In this respect universities are complex, in that they involve students, staff and external stakeholders, and are located within wider communities. The Healthy Universities approach includes opportunities for individuals to be given a voice and shape policy , services, information and projects—and can usefully explore how people interact and find meaning within the setting, appreciating that these interactions have the capacity to either support or impact negatively on well-being. While it is important to acknowledge the reality of continuing health ‘problems’, illnesses and needs, the Healthy University approach must continue to assert its salutogenic focus, supporting its community to thrive and flourish.

It is fundamental that this multilevel approach to salutogenic policy and practice in universities is supported by a focus on salutogenic research. There is currently a lack of salutogenic research that focuses on health creation and maintenance and looks at the underpinning processes in higher education settings that are health enhancing and strengthen ‘sense of coherence’ (i.e. comprehensibility, manageability and meaningfulness). This requires researchers to consider felt and expressed improvements in health and well-being within the context of a whole system orientation—and to explore what a salutogenic orientation can do for the core business of universities. This would also contribute to the development of evaluative research and the strengthening of the evidence base for Healthy Universities.

Conclusion and Challenges for the Future

Looking to the future, the Healthy Universities approach offers enormous potential to support the creation and maintenance of health and flourishing of students, staff and the wider community. There are, though, challenges to face.

Firstly, higher education as a sector does not exist primarily to promote health. In seeking to embed a commitment to health, it is therefore imperative that we are able to demonstrate and illustrate how investment in well-being can contribute to the delivery of core business goals.

Secondly, the language of ‘health’ still tends to be closely aligned with concepts of illness and disease. It will therefore be necessary to engage with ‘pathogenic’ perspectives and the very real health problems facing universities, but to shift the orientation towards salutogenesis. Through exploring how health can be a resource to support core university business, it is possible to make the case for harnessing and strengthening positive health assets and potentials.

Thirdly, many determinants of both illness and health and human potential are located outside of universities. This highlights the importance of strengthening the advocacy role of universities to call for action and become a powerful force for positive change, helping to create conditions that support well-being, cohesion, inclusion, sustainability and social justice within universities, their local communities and society as a whole. It is evident that universities play an important role in training staff and educating students in ways that increase understanding of the determinants of health and health equity and unleash multisectoral innovation, creativity and passion for well-being, sustainability and social justice.

Discussing sectoral developments within higher education in the UK, Steuer and Marcs (2008) critique a perceived over-emphasis on economic development, which they see as fuelling individual competitiveness. In response, they advocate a transformative approach to quality in higher education that serves the dual purpose of enhancing both personal and collective well-being—prioritising features such as enjoyment and fulfilment; autonomy and reciprocity; connectedness and belonging; and empowerment and ability to effect change. Such an approach offers a potential way forward for strengthening comprehensibility, manageability and meaningfulness within the university setting.