Bridging discourses on health promotion and social sustainability towards healthy community development

Abstract

The aim of this paper is to argue for the need to bridge the discourses of health promotion and social sustainability as an important step toward healthy community development. By building on theories and empirical knowledge from both disciplines, we advocate for the field of health promotion to take a more assertive role within the social sustainability discourse because the theoretical and empirical knowledge from health promotion research is needed. Likewise, we argue that the strong emphasis on social justice and contextual community factors within the social sustainability discourse could contribute to developing the health promotion discourse. Furthermore, we suggest that place-based methods and analyses used in current health promotion research could serve as tools to better integrate knowledge on both physical and social dimensions, thereby enhancing inter-disciplinary collaboration to develop socially sustainable communities.

Keywords

Health promotion social sustainability community development settings-based approach neighbourhood equity social justice

Background

Introduction

The focus on social sustainability is increasing and has gained prominence on the political agenda during a time of fragmentation of the Nordic welfare state and growing socioeconomic disparities [1]. Given the shared emphasis on equity and the creation of local communities that satisfy human needs, health and well-being [2,3], it is a paradox that the concept of social sustainability appears to be considered in the research literature on health promotion to a limited degree. Conversely, knowledge and theories used within the field of health promotion seem to be more or less absent in the literature on social sustainability [4]. This might be because health promotion is often primarily the concern or responsibility of health professionals in municipalities, while social sustainability is primarily an area of focus among local government planners [5]. Similarly, the process of conceptualizing and operationalizing social sustainability in research has mainly taken place within academic fields such as planning, urban development and architecture [4]. Moreover, the commonly narrow understanding of the concept of sustainability as solely environmental sustainability may have obscured the link between health and sustainability [6]. In this paper, we will discuss the importance of bridging perspectives on health promotion and social sustainability, with a particular emphasis on how knowledge from the field of health promotion can enrich our understanding and contribute to further developing the concept of social sustainability. As the physical and social dimensions of places and settings appear to be the frames around which health promotion and social sustainability perspectives converge, we will elaborate on how to better integrate knowledge on both dimensions to foster socially sustainable communities. This will be exemplified through research using place-based analyses to assess use of the neighbourhood spatial context for social purposes.

Why bridging health promotion and social sustainability is important

Since the launch of the Brundtland Commission report on sustainable development in 1987 [7], there has been an ever-increasing focus on sustainability, which was further boosted in 2015 when all United Nations Member States adopted the 17 Sustainable Development Goals (SDG’s) as a shared global framework [8]. Sustainability is commonly described as consisting of three equally important pillars or dimensions: environmental, economic and social sustainability [9]. While considerable attention has been given to the environmental and economic dimensions, the social dimension still lacks broad grounding and has even been labelled ‘the missing’ or ‘the forgotten’ pillar [10,11]. Unquestionably, it is urgent to address environmental and economic sustainability when addressing social sustainability. From a health promotion perspective, it is crucial not to leave the social pillar behind as this pillar puts human needs and well-being at the forefront.

On the positive side, over the past decade there has been a growing recognition of the importance of embracing the social dimension when addressing sustainability [12,13]. This growing attention has been triggered by the need to address and discuss environmental sustainability in the context of people and politics, as well as by the understanding that social sustainability is important and valuable in itself [1,14]. Recently, the COVID-19 pandemic showed us the value of socially sustainable societies. Trust, which is a core component of social capital, is considered a central component of social sustainability [15], and during the pandemic high levels of trust in authorities were crucial for people’s willingness to adhere to necessary measures that were implemented [16,17]. A stronger focus on social sustainability is also mirrored in policy documents, and governments and policymakers are increasingly emphasizing its importance [18 –20]. Likewise, the amount of research addressing social sustainability has increased steadily over the last decade [13], but perspectives from health promotion have been limitedly visible in the literature about social sustainability to date [4]. This is unfortunate as bridging perspectives from health promotion and social sustainability could be an important step towards strengthening the role of the social pillar within the sustainability debate. This is paramount as the three sustainability pillars are mutually dependent, conceptually inseparable and practically indistinguishable to ensure sustainable development [21]. To grasp how knowledge from the field of health promotion could enhance the social pillar, we should take a closer look at the concept of social sustainability.

What is social sustainability?

In the research literature, myriad definitions of social sustainability exist [21,22]. Many of these definitions are linked to a place, such as Woodcraft’s definition of social sustainability as a process for ‘creating sustainable, successful places that promote well-being by understanding what people need from the places in which they live and work’ [3], whereas some interpretations and definitions are more people-orientated and refer to ‘maintaining or improving the well-being of people in this and future generations’ [23]. These highlighted definitions share some core dimensions that are relevant from a health promotion perspective. First, the definitions recognize the goal of promoting well-being. Second, they consider the interrelationship between people and places, with a strong emphasis on places, which are often referred to as settings within the health promotion discourse [24]. Third, they concern the significance of providing opportunities and resources that people need within the local community.

Alongside attempts to define the concept, many scholars have sought to conceptualize social sustainability and suggested frameworks for doing so [11,12,14,15,25]. The studies investigating social sustainability mainly originate from research traditions such as urban planning, public administration, political science, architecture and urban studies [4,11]. Consequently the current ways of conceptualizing and operationalizing the social dimension of sustainability are heavily influenced by these traditions. This is visible through a somewhat skewed emphasis on the physical environment [4]. However, non-physical or social factors are also included, and despite criticism that the concept of social sustainability lacks a clear and coherent understanding [10], there appears to be a set of key components embraced by most scholars and policies. These components include non-physical factors such as equity or social justice, social capital, social cohesion, place attachment and safety, in addition to physical factors related to neighbourhood qualities, such as housing, access to local services, green space and transportation [4,11,13,15,26].

Interestingly, there has been a shift in conceptualization from ‘hard’ concepts (such as physical neighbourhood qualities) to more ‘soft’ qualities (such as social capital and social cohesion) within the social sustainability literature [27,28]. This shift has been applauded and described as an advantage for the social sustainability discourse by some authors, as the discourse could ‘benefit from the well-developed arguments of these concepts and their scientific achievements’ [27]. Some authors within the social sustainability literature have also advocated for using well-established conceptual frameworks or approaches from health promotion, such as social infrastructure and quality of life [29] or Amartya Sen’s capability approach [30], to more effectively operationalize social sustainability. Janssen et al. [30] very importantly suggest that such an approach could redirect the focus of assessing social sustainability from evaluating the means (i.e. urban resources) towards assessing the ultimate endpoint or goal (i.e. the well-being of citizens).

However, from a health promotion perspective, the conceptualization and theoretical understanding of these ‘soft’ indicators appear deficient within the current social sustainability literature. Moreover, a recent review of indicators applied to measure social sustainability showed that ‘hard’ indicators are still predominantly used [4]. In the health promotion literature, on the other hand, ‘soft’ factors are commonly applied as determinants for health and well-being. One such example is social capital, which has been extensively studied and understood in relation to health for a long time [31 –33], also in order to assess social sustainability in urban and local development [34]. Therefore, along with several other reasons, we will argue that the health promotion discourse has a lot to add to research and practice within the social sustainability discourse. But first, we will briefly discuss some striking similarities between the two discourses.

Social sustainability and health promotion – two sides of the same coin?

The cornerstone of health promotion, The Ottawa Charter for Health Promotion, stresses that good health is not merely the absence of disease, but, rather, health is seen as a resource for everyday life, emphasizing social and personal resources as well as physical capabilities [2]. This has transformed how we think about public health work and constitutes a focal framework addressing major public health challenge [35]. Some of the key strategies highlighted in the Ottawa Charter include strengthening community actions, building healthy public health policies and creating supportive environments for health [2]. The guiding principles within the health promotion discourse are a holistic understanding of health, equity, empowerment, participation, intersectoral collaboration, utilization of a variety of approaches, and sustainability [36]. By emphasizing that ‘Health is created and lived by people within the settings of their everyday life; where they learn, work, play and love’ [2], the Ottawa Charter introduces an important settings-based approach for health and well-being, which has been further developed within the health promotion discourse [37 –39]. A settings-based approach is characterized by a commitment to integrate health and well-being into the cultures, structures and routines wherein people live their lives, focusing on both structure and agency [40]. Further, it is underpinned by values such as equity, participation and partnership [39]. Additionally, the approach adopts a socio-ecological understanding, considers complex systems and maintains a whole system focus [39].

The discourses of social sustainability and health promotion have developed in parallel since the middle of the 1980s, and as the observant reader may have already recognized, there are several major overlaps and similarities between the two. First, both discourses focus on human needs and well-being and how to ensure environments in which humans can thrive [2,3]. Furthermore, both discourses direct attention to contextual factors. The health promotion discourse emphasizes that health and well-being are created where people live their everyday lives [2]. This means that health and well-being can only be understood and studied in relation to the contexts or settings in which people live. Likewise, social sustainability must be studied in a context-sensitive manner at the community or neighbourhood level [21,41] to understand what people need from the places in which they live to create sustainable places that promote well-being [3]. Second, the two discourses share the understanding that the determinants of health and well-being are complex and intertwined. It is in the interplay between biological, relational, social, cultural, commercial, spatial, multisectoral and political factors that well-being is created [8,40,42]. Third, while acknowledging this complexity, both discourses share some key dimensions that are given particular importance in ensuring human needs and well-being, such as equity, participation, social capital, safety, belonging and neighbourhood quality. Especially, equity or social justice seems to be a core value shared by both discourses. The principle of social equity is strongly embedded in the understanding of sustainable development, and most scholars include social equity, or the closely related term social justice, as an important dimension of social sustainability [11,15,43]. Social equity has also long been recognized as an important prerequisite for health and well-being [44 –47]. Fourth, both discourses struggle with some common challenges. They both deal with concepts that are subjective in nature, often measured by ‘soft’ and intangible indicators perceived as difficult to measure [10,12]. Furthermore, even if measured, the value of such subjective concepts has traditionally been met with uninterest, or even scepticism, in adjacent fields such as medicine [48], architecture [49] or economy [50]. Fifth, both discourses aim to solve so-called ‘wicked problems’ where the causal structure is multifactorial and complex, calling for interdisciplinary and multisectoral action [51]. Last, both social sustainability and health promotion deal with normative values, for example, how society ought to be [6], and navigating normative aspect can be challenging for many public sector entities as well as researchers [11].

The substantial overlap between the two discourses is also reflected in policy documents. A Canadian study investigating policy documents for social sustainability in six municipalities revealed significant alignment with key health promotion action strategies and common determinants of health highlighted in the Ottawa Charter [5]. Similarly, another study analysing community plans from several different countries found that emphasizing quality of life was one of the most important dimensions linked to achieving the overall shared vision of social sustainability for the community [52].

The benefits of bridging the two discourses

Until now, we have discussed and clearly illustrated that health promotion and social sustainability overlap in many aspects, sharing common goals and visions. Thus, we argue that both discourses could add substantial value to each other by integrating and exchanging knowledge. The strong emphasis on contextual and social community factors within the social sustainability discourse could contribute to enhancing health promotion. Despite the longstanding recognition of the important role structural and societal factors play in creating good health and well-being within health promotion, research shows that interventions and policies often still focus on individual responsibility and approaches [6,53 –55] and this focus remains persistent [56,57]. Furthermore, the strong emphasis on the physical and built environment as important aspects of a place found within the social sustainability discourse could raise awareness about also including these factors in studies using a setting-approach of health promotion. Another aspect where the health promotion discourse could benefit from joining forces with the social sustainability discourse is through the latter’s strong focus on equity and social justice [11,15]. As health and societal inequalities continue to grow within the Nordic welfare states and elsewhere, addressing sustainable health promotion in terms of equity becomes increasingly crucial [47].

On the other hand, frameworks and theories used within the field of health promotion seem to be partly missing in the literature on social sustainability [4]. In a recent scoping review of social sustainability frameworks, Ånestad et al. [4] identified only five out of 22 frameworks that included health and well-being in their conceptualization of social sustainability. Interestingly, health was mainly operationalized through objective indicators such as mortality rate or the presence of health care facilities in these frameworks [4]. This represents a rather narrow understanding and way of operationalizing health and well-being contrary to the context of health promotion, where health is regarded as a resource that allows people to live fulfilling lives and contribute to society [2,24]. Moreover, hedonic well-being, which relates to people’s feelings and emotions, as well as eudaemonic well-being, which considers psychological functioning, meaning, and purpose in life [58], are rarely included in the frameworks [4]. In this area, the health promotion perspective could enrich the social sustainability discourse to embrace more subjective dimensions of health and well-being.

As described earlier, the concept of social sustainability has been stated to face theoretical challenges [12,21]. Moreover, there appears to be a weak theoretical understanding or awareness of how societal structures, physical surroundings and social factors interact and mutually influence each other [4]. This represents another area where we believe knowledge from health promotion research can make a substantial contribution. At the core of health promotion are holistic and socio-ecological approaches to health and well-being, and several models have been developed to visualize the main determinants of health and well-being of populations [59]. Such models could provide solid ground for further developing the theoretical understanding of social sustainability. Nevertheless, it seems that models like the ecological systems theory [60], the rainbow model [61] or the more recent health map for the local human habitat [62] have not yet been applied or considered in the social sustainability literature [4]. Even though such models, like the rainbow model, are not designed to be an analytical tool for empirical testing of causality [63], they still visualize the interconnected layers and point to the fact that determinants in different layers influence each other. Somewhat surprisingly, there is a lack of research suggesting or investigating causality or interactions in the social sustainability literature, with some exceptions [41,64]. To put it bluntly, most of the social sustainability literature suggests that both the built environment and social factors are of importance for socially sustainable community development. However, the literature often falls short of proposing causal relationships or explaining how these factors might interact, and why or how these factors influence human well-being. Thus, in what follows, we will round off the discussion on how knowledge and methods used within health promotion such as socio-ecological models and settings-based approaches can add valuable information for developing socially sustainable communities. We will illustrate this with an example of how the interplay between the built environment and social factors can be assessed simultaneously following the principles of socio-ecological models.

Understanding the interplay between the physical environment, social dimensions and well-being through place-based analyses

While existing social sustainability frameworks fail to consider how the societal, physical, cultural and social environment interact to influence health, well-being and social sustainability [4], efforts have been made to understand such connections for different health-related outcomes within the health promotion discourse by using socio-ecological models and a settings-based approach [54,65,66]. For the particular interest area of the physical or built environment found in most of the social sustainability literature, it would be useful to look into health promotion research taking a socio-ecological approach to the neighbourhood physical environment as a setting through which social life and networks can be nurtured to enhance well-being [67,68]. Such an approach also formed the basis for a study that we herein present as a practical example of how interdisciplinary knowledge and methods including the health promotion perspective could add important knowledge to ensure socially sustainable neighbourhoods. The study aimed to examine how the neighbourhood built environment related to sociability modes, and what role this played for inhabitants’ sense of belonging to the community and subjective well-being.

An important aspect of the study was to consider the physical environment and social dimensions in integrated manners. Therefore, a place-based approach and methodology were utilized. Place-based approaches are context-dependent and draw on local knowledge and experiences of residents to address issues within specific geographic locations [69,70]. The current study was conducted within Kvernevik, a neighbourhood with approximately 5700 inhabitants located in Stavanger municipality, Norway [71]. Area-based urban renewal is currently taking place in Kvernevik, and the municipality requested knowledge about the residents’ use of the physical environment to inform upcoming planning processes [72]. To capture the spatial context of the residents’ social activity patterns, we used public participatory geographical information systems (PPGIS) methodology. PPGIS refers to a growing field of digital participatory mapping methods that are well suited to locate residents’ spatial behaviour, diverse environmental experiences, and development preferences in place-based manners [73,74]. Importantly, PPGIS methods are customizable to answer specific knowledge needs in local settings, such as neighbourhoods and municipalities [75].

Health promotion researchers, municipal planners and landscape architects in Stavanger designed a web-based survey combining internet maps with conventional survey questions using Maptionnaire^®, which is a PPGIS-based tool. Through the web-based survey, the residents mapped their home location, as well as the places where they participated in activities, on a map. The mapping provided us with the geographical coordinates of each mapped site, which enabled us to pinpoint the exact spatial locations of the residents’ activities. To obtain detailed information about each mapped place, there were several follow-up questions to be answered by the residents during the mapping. The questions covered how often they visited the place, with whom they visited the place, mode of transportation to the place and to what extent they felt safe at the place. In addition, there were open-ended questions where the respondents could specify experiences or activities at the places they mapped, and if they were socializing with other people, they could indicate how many people were present together at the place. The survey also included questions covering life satisfaction, neighbourhood satisfaction and safety, and sense of belonging to the community. The place-based analysis showed that the places used for various social purposes were mainly located in Kvernevik centre, where the school and sport arena are situated, while areas along the coastline were more commonly used alone or with family members. This shows that it is possible to link the physical environment to social factors, and we argue that this could be a fruitful approach for developing knowledge that helps us move towards socially sustainable community development. Also, methods such as PPGIS could facilitate collaboration between different professionals in a municipality engaged in health promotion and planning. Since planners are already familiar with maps and geographical information systems, PPGIS might increase their interest and improve their understanding of creating health-promoting communities. This is important as more inter-disciplinary collaboration has been emphasized within the social sustainability literature as necessary to advance theoretical knowledge on social sustainability [44].

Conclusions

Social sustainability has gained traction on the political agenda [1]. Given the substantial overlap between social sustainability and health promotion, we argue that bridging the two discourses would be mutually advantageous. From a health promotion perspective, we believe that scholars within health promotion could take the opportunity to secure a more prominent role in developing the theoretical and empirical foundation of social sustainability rather than leaving it to academic fields that primarily study the physical surroundings, such as urban planning, architecture, and other. Within the health promotion discourse, there has been a long-lasting focus on how the societal, physical and social environments influence health and well-being within different settings; however, the socio-ecological approaches to health and well-being are not yet included in theoretical or empirical research on social sustainability [4].

Likewise, the strong emphasis on social justice and contextual community factors found within the social sustainability discourse could contribute to supporting and further developing the health promotion discourse. Therefore, an important area of focus for future health promotion lies in strengthening the social dimension of sustainability when developing strategies for health promotion and sustainable development [76]. More broadly, the overlapping aims of the SDGs with the health promotion agenda are stated to bring health promotion forward [77], and the importance of aligning strategies for health promotion with strategies for sustainable development has been emphasized [5]. Finally, the shared focus on building community capacity provides a common ground for municipal planners and health promotion professionals to collaborate in enhancing health and well-being [5]. Thus, fostering stronger interdisciplinary collaboration between the field of health promotion and the field of social sustainability can yield mutual benefits, ultimately advancing the common goal of healthy community development.

Footnotes

Declaration of conflicting interests

The authors have no conflicts of interest to declare.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: FORTE (grant number: 2022-01357) and the Swedish Research Council for Sport Science (grant number: 2020/3, P2021-0065).

ORCID iD

Camilla Ihlebæk

Ragnhild Ånestad

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