Settings for the development of health literacy: A conceptual review

This year marks the 30th anniversary of the Dahlgren and Whitehead model of the main determinants of health, sometimes known as 'The Rainbow Model'. In this article, we reflect on developments over those thirty years before going on to look to the future. We start by telling the story of our model's idiosyncratic journey from initial rejection to worldwide acclaim. We reflect on the many ways in which the model has been used over the years and why it has proved illuminating for people in so many different positions. It is equally important to understand what it does not do and what it was never intended to do, as sometimes the conceptual debate gets side-tracked by mistaken assumptions. We take some space to outline how we ourselves use the model with the complementary Diderichsen Framework to explain the pathways and mechanisms by which the known determinants of health bring about the social gradients in health that are observed within countries. We conclude by looking to the future and what further needs to be done to capture insights for action on the determinants and drivers of health and of growing inequalities in the post-pandemic world. Show more

This paper starts by briefly reviewing the history, theory and practice of the settings approach to promoting public health--highlighting its ecological perspective, its understanding of settings as dynamic open systems and its primary focus on whole system organization development and change. It goes on to outline perceived benefits and consider why, almost 20 years after the Ottawa Charter advocated the approach, there remains a relatively poorly developed evidence base of effectiveness. Identifying three key challenges--relating to the construction of the evidence base for health promotion, the diversity of conceptual understandings and real-life practice and the complexity of evaluating ecological whole system approaches--it suggests that these have resulted in an ongoing tendency to evaluate only discrete projects in settings, thus failing to capture the 'added value' of whole system working. It concludes by exploring the potential value of theory-based evaluation and identifying key issues that will need to be addressed in moving forward--funding evaluation within and across settings; ensuring links between evidence, policy and practice; and clarifying and articulating the theories that underpin the settings approach generically and inform the approach as applied within particular settings. Show more