CLINICAL ISSUES

Before the cradle and beyond the grave: a lifespan/settings-based

framework for health promotion
Dean Whitehead

Aim. To develop a unique framework which combines the concepts of settings and lifespan where they are applied to health
promotion.
Background. The influential World Health Organisations 1986 Ottawa Charter for Health Promotion supported certain
settings being nominated as unique social systems for enabling specific health promotion activity. These initially included a
whole raft of proposed settings ranging from the micro to macro; these at the time mainly being hospitals, communities, schools,
workplaces, cities, villages, islands and the home and family. Several other settings have since also been added to the list which
now include health-promoting universities and health-promoting prisons. Most of the mentioned settings have in more recent
times being acknowledged in the nursing literature.
Design. Discursive.
Method. A critical examination and exploration of the existing health promotion literature related to both settings and lifespan.
Results. It is possible to combine the related, but hitherto unexplored, concepts of health promotion settings and lifespan. This
has resulted in a useable framework to further assist practitioners with their health promotion work.
Conclusion. What has not yet surfaced in both the nursing and the general health promotion literature is that most settings can
be linked as a whole, not just by their geographical location and proximity to each other, but also to the fact that they tend to
follow a linear direction that ranges across the total lifespan.
Relevance to clinical practice. Viewing health promotion in the way that this framework proposes further assists in locating and
clarifying the often confused and contested position of health promotion in nursing.
Key words: health promotion, health-promoting settings, lifespan, nursing
Accepted for publication: 22 November 2010

Introduction
In the mid-1980s, the World Health Organisation (WHO
1986) released the highly influential Ottawa Charter for
Health Promotion. One of the milestones of the charter was
that it paved the way towards the development of a series of
settings-based health promotion strategies, where specific
health-related settings were designated for special attention
(WHO 1986). This position has continued through to today
with authors such as Weare (2002) stating that the settingsAuthor: Dean Whitehead, MSc, PhD, RN, Senior Lecturer, Massey
University, College of Humanities and Social Sciences, School of
Health and Social Services, Palmerston North, New Zealand
Correspondence: Dean Whitehead, Senior Lecturer, Massey
University, College of Humanities and Social Sciences, School of

based approach to health promotion remains the big idea of

the WHOs vision for current and future health promotion
strategy. Kickbusch (2003, p. 385) describes the settings
approach as the WHOs second major innovation and the
new concept of health promotion. The Ottawa Charter
supported certain settings being nominated as unique social
systems for enabling specific health promotion activity. These
initially included a whole raft of proposed settings ranging
from the micro to the macro; these mainly being hospitals,
communities, schools, workplaces, cities, villages, islands and
Health and Social Services, Turitea Campus, Private Bag 11 222,
Palmerston North, New Zealand. Telephone: +06 356 9099 ext.
7227.
E-mail: D.Whitehead@massey.ac.nz

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doi: 10.1111/j.1365-2702.2010.03674.x

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D Whitehead

the home and family. Several other settings have since been
added to the list which now include health-promoting
universities (Gosline & Schank 2003, Whitehead 2004a)
and health-promoting prisons (HPP) (Watson et al. 2004,
Whitehead 2006a). In line with this sentiment, some nursing
authors have also hinted at the possibility of establishing
other unique settings such as health-promoting nursing
homes and churches (Wass 2000, Peterson et al. 2002). That
said, a degree of restraint is recommended against what
constitutes a health-promoting setting. For instance, while
those settings mentioned so far seem credible others may
appear less so; such as with health-promoting beauty salons
(Linnan & Ferguson 2007).
Most of the just-mentioned settings-based articles are
nursing-based examples. This indicates that nursing is aligning itself to become well positioned in acknowledging and
influencing emerging settings-based health promotion concepts and contexts. It is argued here, however, that most of
the nursing-based health promotion literature that explores
health promotion settings tends to focus on one particular
client group that of the middle-age to older adult (Nunez
et al. 2003, Resnick 2003, Runciman et al. 2006, Kelley &
Abraham 2007). Some time ago, Gillis (1993) suggested that
most health promotion tools in use have only been developed
and tested on an adult population and that these are not
appropriate for those at each end of the lifespan continuum.
That limitation is perhaps just being realised in the nursingbased age-specific health promotion literature. Particularly,
authors are starting to recognise the importance of aligning
health promotion issues across the early lifespan to settingsbased contexts such as, from maternal, to child, to youth
and to family (Hartrick 2000, Mefford 2004, Roden 2004,
Vonderheid et al. 2007, Barnes & Rowe 2008). Several
books also attempt to address issues of health promotion
related to general lifespan and, in some cases, refer to
elements of settings as they do so (Cattan & Tilford 2006,
Murray 2008, Edelman & Mandle 2010). However, this
literature usually addresses issues from a piecemeal perspective rather than across the whole lifespan continuum.
Therefore, this article is unique in proposing that the current
lifespan continuum is both linked up and extended for
nursing-based health promotion strategy. This would have it
incorporate preconceptual care, to preschool, to school, to
university, to workplace, to retirement and even through to a
health-promoting death and beyond. The beyond death
notion relates to faith-based/existential beliefs around potential afterlife or transcendental considerations that are
elaborated on later in this article. Linking all of these
contexts could have nurses uniquely viewing and implementing health promotion as a rights of passage for all
2184

clients, from preconception through to the grave. Not all

clients share the same health journey, though; so part of the
consideration for viewing health promotion this way is to
individualise it to each person dealt with. For instance, not all
clients will go to university, be unemployed or encounter the
prison setting.
Misra et al. (2003) have already identified that health
promotion approaches that consider the entire lifespan
alongside multiple determinants need to be adopted but, so
far, none have done so. Nearly 20 years ago, it was argued
that nursing needed to develop age-appropriate instruments
for health promotion practice (Gillis 1993). The aim of this
article is to propose a novel age and settings-appropriate
framework for the health promotion practice of all health
professionals, but with a particular slant towards nursing. It
puts forward for consideration a hitherto unacknowledged
proposal for implementing wider health promotion strategy,
aligned within the context of full lifespan and the related
settings that individuals encounter in their lifelong health
journey.
What health promotion is or is not has been very well
contested in the nursing literature to date (Whitehead 2004b,
2009, 2011, Rush et al. 2005, Casey 2007, Holt & Warne
2007, Irvine 2007, Piper 2008, 2009, Whitehead & Irvine
2010). While much of this literature is critical of the fact that
many nurses have been confused about what constitutes
health promotion practice, it is argued here that this situation
should be changing. Therefore, it is not the intention of this
article to define and contextualise health promotion and
health education concepts. The reader, if unsure, can instead
refer to the plethora of just-mentioned studies that already do
this.

A lifespan-settings-based framework for health

promotion
Health promotion takes place in settings environments
where people learn, work, play and love. (Hesman 2007,
p. 175). This type of sentiment necessitates a structured
approach to aligning health promotion settings alongside the
lived lifespan, where all these activities take place. Best et al.
(2003) advocate the application of integrated health promotion frameworks that incorporate systems-thinking to achieve
more effective health promotion dissemination. They argue
that this leads to a more comprehensive understanding of
cause-and-effect dynamics and a further understanding of
health promotion problems rooted in systems of processes,
structure and meaning. Poland et al. (2005) are also critical
that there is little guidance and few attempts in the literature
to systematically unpack key dimensions of settings. In line

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Clinical issues

A lifespan/settings-based framework for health promotion

G.P.'s/
clinics

Health
services

Hospitals

Nursing
homes

Hospices

Community/
home

Community/
home

Home/school

School

Workplace

Workplace/
community

Community

Community

Preconceptual
stage

Maternal/
infant stage

Pre-school
stage

School-age
stage

Work-place
stage

Preretirement
stage

Retirement
stage

End-of-life
stage

Church

University

Prison

Figure 1 The lifespan/setting continuum.

with these sentiments, Fig. 1 schematically demonstrates this

articles proposed health-promoting lifespan continuum and
its stages, as they relate to various proposed settings. It is not
a complex schematic and is designed to draw the consumer
immediately to its central premise of whole lifespan as a
continuum and how it relates to specific settings at given
times. The other main continuum associates related settings
as an actual sequence that is likely to be experienced by
most people as a routine rights of passage progression
through the lifespan. The two more peripheral outer continuums acknowledge potential health-related settings and
settings that may not make up the normal sequence of most
individuals life health journey. Identifying and linking up
these continuums acknowledges Dooriss sentiment that
Peoples lives straddle settings (Dooris 2004, p. 58). He
precedes this by stating that:
Quite apart from the fact that one setting can learn from another, it is
clear that in relation to health-related topics, an issue impacting on
health in one setting frequently has its origin or solution in another.

Perhaps a little tongue-in-cheek here, but with a serious

undertone, it is suggested in the framework that individuals
might evaluate their overall health journey. From a faithbased belief i.e. reincarnation, karma etc, the oft-cited phrase
what we do in this life echoes in the next may be significant
whether that be early on or later in life. The cyclical potential
of Fig. 1, despite its linear inclination, acknowledges the
possibility that the current health journey of individuals may
impact on the next (Speck et al. 2004, Pesut 2008). This
notion relates to faith-based/existential beliefs around potential after-life, pre-life or transcendental considerations
(Sandelowski 2002). It also relates to Newmans notion of
evolving consciousness as a complex expansion where
clients recognise an internalised power to move to higher

levels of consciousness as part of lifes health goal. Individuals

are recognisable components (a discrete energy signature) but
still part of the larger whole cosmos (Barnum 2011).
In a further related sense early in the following section,
preconceptual health promotion is discussed, which argues
that health outcomes for individuals may well be determined
at the molecular level, through their DNA sequencing and
inherited genes. Seibert (2010), a Director of Family Nurse
Practitioner Services in the US, suggests that genetic
preventative health care has been part of clinical practice
for other health disciplines for years, with nursing beginning
now to realise its health promotion potential. She adds that
its future applications are almost limitless. Shonkoff et al.
(2009, p. 22542255) refer to biological embedding and
the effects of epigenic pathways (above genetics) where
alterations of genes across generations are caused, not by
genetic inheritance, but by early stress-related experiences of
individuals:
in DNA methylation and histone modification of chromatin in
response to environmental cues that, in turn, influence how the next
generations genes are expressed.

These evolutions in health care lend even more weight to the

conceptual claims that what individuals do in this life and
beyond has a potential health promotion legacy that is worth
investing in for the health of future generations. Nurses are
involved in client-based care at all stages of the lifespan
continuum and also practice and/or socialise in all the
identified health promotion settings. In essence, they are in
a good position to influence developments in this area of
health care. The next section explores in more detail the
nature and scope of a lifespan continuum for health promotion and, where applicable, relates this to a settings-based
perspective.

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The health promotion lifespan continuum

Preconceptual stage
Especially because of recent medical and technological advances, it is now feasible to realistically consider the health
promotion of people even before they are born. Powerful
influences on health outcomes of individuals later in life are
known to occur long before pregnancy occurs. Misra et al.
(2003) believe that more attention should be focused on
health promotion interventions at the preconceptual and
interconceptual level as a means of improving the perinatal
health of individuals. Preconceptual health promotion strategies target would-be parents to try and offer their children
the healthiest start in life and, subsequently, a much greater
chance of lifelong positive health and well-being. Hobbins
(2006), a nurse practitioner, presents a very strong case for
implementing preconception-based care as one of the most
effective means to ensure this is the case in both mothers and
their offspring. In relation to this, the principles of evolutionary biology begin as early as the first weeks after conception (Shonkoff et al. 2009).
In the not-too-distant future, it is foreseen that the
influence of biomedical technology, such as with gene
sequencing, genome therapy and stem cell treatments, will
heavily influence and predetermine the lifelong health status
of individuals. This will often occur at the time of in-vitro
fertilisation or even before conception. Butler et al. have
hinted at the possibility that, one day soon, we may witness
genetic alteration techniques that will postpone ageingrelated diseases and extend lifespan. They believe, as others
do too, that this will herald in a new era of preventative
medicine and health promotion related to extending healthy
lifespan (Olshansky et al. 2006, Butler et al. 2008, Kirkwood
2008). Interestingly, Richard et al.s (2010, p. 454) recent
study, describing Public Health Nurses practices, states that
they identify health promotion as early action before a
problem has arisen occurring over a lifelong period and
could begin even in utero for a better outcome later. Issues
of access, efficacy and ethical policy of such treatments and
interventions will no doubt underpin an important role for
health promoters in this field of eventual health care. In
todays terms, perhaps the most notable global preconceptual
health promotion intervention is the advocating for folic acid
in common food products, such as bread, to help prevent
developmental disabilities in children. Howell et al. (2001)
stress the effectiveness of simple health promotion measures to introduce folic acid consumption to a young and
disadvantaged population with high birth rates. Another
important consideration for this stage is the fact that delayed
childbearing among older women, as a more recent socio2186

logical phenomenon, draws attention to the need for even

greater health promotion vigilance on the part of health
professionals (Misra et al. 2003). For those interested in
further information on genetics and genomics and the role of
nursing in this developing field, De Sevos (2010) article is a
useful resource.
Maternal/infant stage
This is an important stage of any individuals health development and a likely indicator of future health status. In this
phase, Kotelchuck (2003) states that health promotion
communities view access to effective prenatal care as the
major public health solution to the reduction of health disparities in birth outcomes. Beldon and Crozier (2005) identify that much of the role of the midwife during pregnancy is
in health promotion but reiterate that it may not be identified
as health promotion. She stresses that midwives should work
in partnership with women and families and other agencies
to facilitate decisions about care that mothers require prior to
and after birth of their children and further identifies that
health promotion strategies should focus on young mothers
from socially disadvantaged groups. Similarly, Domian et al.
(2010) highlight the active health promotion role of Public
Health Nurses working with disadvantaged mothers in their
My Baby and Me comprehensive parenting intervention
programme. In these ways, it is anticipated that young women will come into contact with midwives and nurses before
the momentum of preconceptional care is lost and before
negative attitudes to breastfeeding are established. This type
of intervention is at the heart of current public health policy
around childbirth and child-care, where the emphasis has
moved from individual behavioural-change to inequalities in
society. Pearce et al. (2008) also highlight the active commitment of midwives towards health promotion reorientation of health services, but they too highlight major barriers
in doing so. They do add, however, that some services (such
as maternal vaccination) suffer more so than other maternal
health promotion services i.e. breast-feeding support. Housten and Cowley (2002) furthermore suggest an integrated
approach to needs assessment using an empowerment
framework for health visitors working in the community/
home setting. They suggest that health promotion and
empowerment are central to health-visiting practice, where
approaching individual needs assessment does not compromise the ethos of partnership-working in a health-promoting
way. From a more biological perspective, Shonkoff et al.
(2009, p. 2257) state that the origins of adult diseases are
found in the developmental and biological disruptions
occurring in the very early years of life. They stress that it is
these years that:

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Clinical issues
establish biological memories that weaken physiological systems
and produce latent vulnerabilities to problems that emerge well into
the later adult yearsproviding a compelling rationale for considering
the inclusion of health promotion and disease prevention as a fully
integrated part of that [neuroscience] agenda.

Kindergarten/preschool stage
The concept of health-promoting schools (HPS) is one of the
more visible in the nursing and general health promotion
literature. However, the notion of health-promoting preschools, day-care education or kindergartens is not well
established (Dresler-Hawke et al. 2009). McKey and Huntington (2004) discuss the implications for nursing in the area
of child health practice related to the highly topical and relevant issue of preschool childhood obesity. They state that
nurses working in this area need to develop an understanding
of the complex and often emotive issues at hand and an
awareness of the reality of peoples lives when devising health
promotion strategies for this target group. Perren and Alasker
(2006) provide novel findings that help to put in place lifelong anti-bullying strategies as they impact on the mental
health of individuals and peer groups. They investigated
varying bullying behaviours of children at the level of preschool kindergarten and later links to mental health states
throughout the lifespan. The outcomes were especially linked
to how children fared when they moved into the school
setting.
School stage
The school setting is seen as one of the most important
health-related growth and frontline defence areas for health
promotion and health education intervention, where health
promotion policies are a vital and integrated part of national
curricula and health services (Tossavainen et al. 2004,
Dresler-Hawke & Whitehead 2009). From this position, the
general HPS movement has come of age with a notable body
of nursing-related literature emerging that has begun to develop a coherent and collective health strategy alongside a
growing body of quality outcome-based research evidence to
measure this activity (Wainwright et al. 2000, Bartley 2004).
Many nursing-related groups (including midwifery and
health-visiting services) have links with schools even if these
links are not always obvious. This may be through paediatric,
maternal or social services. It is vital that all these professional disciplines and services intervene at the early stages of
the lifespan continuum in seeking to instil healthy practices
that younger people will then take with them into their young
and middle-adult lives and beyond. Other specific groups,
such as school nurses, health visitors and specialist community public health nurses, will have more obvious involve-

A lifespan/settings-based framework for health promotion

ment in this setting. However, it is noted that their function is

not always as far-reaching a health promotion role as could
be wished for (Whitehead 2006b). The closest examples that
can be found to a collaborative whole-school and surrounding community health promotion capacity and process are
presented in the findings of certain nursing authors (Larsson
& Zaluha 2003, Berg et al. 2004, Eliason & True 2004).
Specific publications, such as the Journal of School Nursing,
highlight important emerging health promotion agendas.
Maenpaa et al. (2007) report their school nurse-led health
project involving Finnish sixth-graders. Twenty-two sixthgraders (aged 1112 years) became participants in their
grounded theory study. Their findings suggested that pupils
thrived and their health benefited where individual counselling and coping skills were reinforced alongside informative
health education interaction with the family unit. The active
role of student nurses on schools-based placement is highlighted by Laughlin et al. (2010). They report their Healthy
Living Project where students practicum experiences involved active application of health promotion aligned to
specific community-based school projects. They combined
service learning with research as part of a growing partnership with local primary and secondary schools.
University/higher education stage
Universities and other higher education settings are not always going to figure in the lives of all clients. More and
more so now, however, greater numbers of individuals are
accessing this type of setting as a routine follow-on to
post-16 school education (Dooris 2009). The university may
not be seen as somewhere where clinical nurses directly
work or influence the health of individuals. However, most
nurses in the world train and are educated through university, college or polytechnic-based diploma/degree awards.
They then often go on to remain in such institutions as they
prepare for postgraduate studies. Universities and the like,
therefore, can be viewed as testing grounds where the theoretical and practical components of delivered health promotion serve as a valuable starting or continuity point for
clinical practice. The university can be seen as not only a
good breeding ground for nurses to learn broad health
policy and health promotion skills, but also a useful location
for disseminating these skills to both a localised and wider
audience (Whitehead 2004a). There are, so far, only a few
examples of nursing-based health promotion in the university setting. For instance, Huyhn et al. (2000), as part of a
university-based teaching-learning community clinical practicum programme, report how nursing students helped to set
up a health information Internet site in an underserved inner-city high school. The programme allowed these students

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D Whitehead

to experience, at first-hand, the sustainable practices of

community-orientated participation. Local solutions to
community health problems were uncovered and credibly
linked to the university sector.
Workplace stage
The health-promoting workplace is fast gaining pace as one
of the more important health promotion settings (Shain &
Kramer 2004, Whitehead 2006c). It holds a unique place
where the health and well-being of workers inevitably impacts on the health of individuals in the workplace setting,
their families, the local community and society at large
(Noblet & LaMontagne 2006, Mills et al. 2007). It would
also be remiss not to consider the further health contribution
that such environments have on those for which health services are primarily designed; the client. Kearsey (2003) has
already highlighted that healthy workplaces also equate to
healthier patients. Subsequently and in line with the public
health commitments of health service organisations, the
extension of a positive healthy culture in the workplace is the
potential influence on the health of immediate and wider
family groups of health employees. As such, Ennals (2002)
reminds us that we are obliged to consider the world beyond
the workplace; the one where nurses are also engaged as
citizens. In this sense, it is wise to consider the image that
health services project into the communities that they serve.
This is not just through the health standards and status of its
patient outcomes but also through the health status of its
local workforces. Similarly, Lavoie-Tremblay et al. (2008)
stress the role of current nurses in creating healthy workplace
environments for the sake of the next generation of nurses to
follow. This will help to temper the affects of projected nurse
shortages and keep the momentum of health-promoting services going forward. It is at this point that a unique cycle is
added to Fig. 1. Particularly, with soon-to-be new mothers
(majority of births occurring at age of early employment) and
fathers, health behaviours at this point profoundly influence
the previously discussed preconceptual stage of the lifespan
continuum.
Runciman et al. (2006) report on their nursing-led health
promotion study into work practices of community nurses
with older people. Their survey revealed that, where effective
and creative group work at the interdisciplinary, multidisciplinary and multi-agency levels occurs, then effective health
promotion activity is subsequently evidenced in the workplace. The barriers to effective health promotion in the
workplace existed where there was a lack of planning
(especially involving clients), audit and evaluation and where
there was a lack of resources and funds. Effective workplace
health promotion may even serve to extend the productive
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working lives of individuals who might, otherwise, contemplate earlier retirement. Tourangeau and Cranley (2006)
investigated the intention of 13,000 Canadian nurses to
remain in employment as they progressed towards retirement.
From measuring predictors to remain or leave employment,
they concluded that strategies needed for nurses to remain
employed included employment practices that reflected moral
integrity, incorporated clear communication systems, maximised employee involvement in decision-making, promoted
praise and recognition and an established shared vision and
goals.
Unemployment/welfare/detention stage
The link between work and socio-demographic status and
healthy ageing is well established (Maltby 2004). It is not to
suggest that people who are unemployed or receiving welfare will go to prison. However, there are established links
between long-term unemployment, low income, geographical location and race that correlate with a higher incidence
of criminality and penal incarceration in these sections of
society which nurses encounter (Hek 2006). Establishing
health promotion strategies in the prison setting is notably
difficult as forced detention works counter to the healthpromoting principles of negotiation, autonomy and
humanism (Whitehead 2006a). However, with regard to
nursing roles, both Condon et al. (2007) and Hek et al.
(2006) elaborate on the growing and significant primary
health care role of penal nurses whose priorities are to address social and health needs of their clients as well as to
improve their individual health status and to prevent reoffending and protect the wider community. Whether
dealing with prison-based or unemployed clients, much of
the health promotion work within this stage would involve
nurses from various disciplines introducing or re-orientating
affected individuals to programmes that rehabilitate them to
become active and productive members of their local community workforce. Laverack and Labonte (2000) advocate
the targeting of traditionally complex social groups, such as
unemployed clients, into health-promoting community
empowerment and advocacy schemes. For those affected
long-term in this stage, part of the health promotion strategy needed would be effective preparation, working alongside those who have always worked in what would
constitute the following pre- and post-retirement stages. The
potential role for nurses in formulating and implementing
health promotion programmes in various settings with
people who are unemployed has been highlighted (Harris
et al. 2009). Martin et al. (2010) describe their nursedeveloped Welfare-Wellness-Work health promotion programme. Through skills and knowledge development, they

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Clinical issues

report positive participant outcomes in terms of increased

self-esteem, self-care and self-empowerment.
Pre-retirement stage
This is a stage of the lifespan continuum that generally has
not been well researched and has only more recently become
accepted as an actual stage on the continuum (Lethbridge
2001). This is despite the fact that the need to promote
healthy active ageing, to offset the impact of an ageing
population on national resources and ensure a high quality
of life in older age, is well recognised. Secker et al. (2004)
refer to this stage as the midlife part of the continuum.
They report their evaluation of a national pre-retirement
health initiative in England. Their findings indicated that
health improvement services could be effectively targeted at
people in midlife and that service settings and style played
an important part in the engagement of this usually neglected client group. Against the known backdrop demographic of the baby boomer generation of the early 1960s,
this generation is in or nearing this stage which most
commonly falls within the midlife/pre-retirement age of 55
65 years. From a settings-based point of view, most health
promotion activity is likely to occur either in the workplace
or, from a social point of view, in local community. It may
also include, as part of or separate to, settings such as
health-promoting churches (Peterson et al. 2002).
Retirement stage
Where pre-retirement ends and actual retirement begins is
an important stage in the health status of individuals and
their closest ones. De Vaus et al. (2007) report on their
prospective longitudinal Healthy Retirement Project study.
They found that retiring gradually allows for clients to
make preparatory changes to their current and future lifestyle. They suggest that health care policies and work
practices that promote control of retirement decisions for
clients will enhance overall well-being later on in life. When
actual retirement occurs, health promotion is of considerable importance for retirees for sustaining a productive and
healthy societal role and function. It is a significant area for
health care workers, responsible for drafting policies and
programs, to consider in helping improve health and wellness in older adults. For nursing, such is the level of health
promotion interest and active engagement at this stage of
the lifespan that a well-crafted nursing-specific systematic
review has been conducted (Wilson & Palha 2007). Although the age of retirement can vary significantly between
individuals, professions and countries, the general rule is
that this age group commences around the 65-year-old
mark.

A lifespan/settings-based framework for health promotion

Kennedy (2006) identified that health-promoting environments found in some naturally occurring retirement
communities may be a low-cost community-based means of
sustaining both the health and the well-being of older
people. He reported on the efforts to link biomedical and
psychosocial services in naturally occurring retirement
communities which assist seniors age in their own homes.
The desired outcomes were optimal health and independence relevant to and mutually desired by both health and
social service providers. Wilson and Palha (2007) conducted a qualitative content analysis systematic review of
the literature related to health promotion of adults at the
age of retirement. Four themes emerged from the analysis
of this literature and are as follows: (1) the considerable
effect of retirement on retiring individuals and thus the
need for support for more positive retirements, (2) identifying and overcoming barriers to health promotion at
retirement, (3) evaluating the methods by which health
promotion is introduced for positive and long-term change
and (4) describing the short- and long-term benefits of
health promotion at retirement. Hitt et al. (1999), in their
study, identified that most centenarians enjoyed a healthy
and independent lifespan usually right up to a rapid
terminal decline. Their compression of mortality paradigm
reported the more positive view that the older an individual gets the healthier they have been rather than the
more commonly held view of the older people get the
sicker they become.
End-of-life/palliation stage
Rosenberg and Yates (2010, p. 201) suggest that health
promotion and palliative care may appear as conceptually
incongruent fields. Similarly, Kellehear (2008, p. 139)
stresses that health promotion and palliative care can appear,
at first glance, as both contradictory and strange companions, with dying patients there is no room for preventative
advice. However, he goes on to highlight that palliative care
is closely related to health promotion as its premise is based
on holistic and humanistic therapeutic care. In this sense, the
role of the nurse is to develop personal skills for clients,
develop participatory relationships, educate and inform clients and families, offer health and death education, social
support and strengthen community action and community
participation. Rosenberg and Yates (2010) propose then that
end-of-life palliative care is, after all, very amenable to the
application of health promotion practice. Richardson (2002)
mirrors much of the above sentiment aligned to the role of
community-based palliative care nurses. In turn, they have
been able to offer a previously absent definition for health
promotion in nursing-based palliation. Both Berg and Sar-

 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 21832194

2189

D Whitehead

vimaki (2003) and Whitehead (2003) have also highlighted

the importance and place of wider existential components of
health promotion that can be linked to this stage. In this
context, clients draw on existential forces to either help
overcome adversity or give strength in facing a peaceful
death. For dying patients, existential strength can offer hope
and, for some, fulfilment. Fulfilment, in this case, may relate
to the previously mentioned notion of faith-related or transcendental beliefs around potential afterlife considerations.
From a settings-based perspective, this stage of the lifespan
continuum could potentially involve health-promoting nursing homes (Wass 2000) and health-promoting hospices
(Richardson 2002).

The potential other settings

It may not always be prudent to refer to all of the recognised
health promotion settings from the point of view of a health
promotion lifespan continuum. For instance, despite their
important place in nursing, direct health care-related settings
such as acute health-promoting hospitals, GPs, clinics,
nursing and rest homes and hospices are not really addressed
in this article. They are, however, represented in Fig. 1. These
types of settings are already comprehensively addressed in the
mostly nursing-based literature (i.e. Chan & Wong 2000,
Wass 2000, Johnson & Baum 2001, Cullen 2002, Richardson 2002, Bensberg et al. 2003, Whitehead 2004c, 2005,
McKinlay et al. 2005, Pelikan 2007, Watson 2008). However, they are not always a natural part of a persons health
journey or it is often difficult to predict when such episodes
will occur. When they do occur, they tend to be short-term
and are not usually the most desirable situations for the
implementation of health promotion initiatives. It is probably
more appropriate, instead, to consider chronic illness and
disability events in the context of social models of community
intervention that promote recovery, rehabilitation and selfmanagement of clients. Such examples are the increasing
number of strategies that promote initiatives such as the
Hospital in the Home and Home Healthcare (Duke & Street
2003, Thome et al. 2003). Similarly, other potential nonhealth care service settings that individuals may or may not
encounter have already been detailed in this article i.e.
universities and prisons or are more generalised or
peripheral to detail separately i.e. churches (Peterson et al.
2002, Gosline & Schank, 2003, Whitehead 2004a, Watson
et al. 2004, Whitehead 2006a). However, because they
potentially still hold an important place in the health journey
of many, these settings are still identified in Fig. 1. For
instance, in DeHaven et al.s (2004) review of health
promotion in faith and religious-based organisations, its role
2190

is seen as extensive. Furthermore, the role of nurses figures

predominantly in the review.

Conclusion
The concept and impact of health promotion settings are well
established in the health care literature (Poland et al. 2000,
Whitelaw et al. 2001, Dooris 2005, Whitehead 2010). What is
less established, however, is the linking up of all settings as
they potentially impact on individuals, groups and communities at various times in their lives. Thinking beyond the scope of
the immediate practice or setting to consider the links between
and influences of other settings has enormous positive health
benefits for those that work in and access them. Poland et al.
(2005), p. 171 stress the importance and uniqueness of
settings-related place in the literature and its profound impact
on health strategy. This includes nursing-based research in
this field. They go on to state that the more common views of
settings-related space and place (either a geometric entity that
impacts directly on the health of health professionals and their
clients or as a locus or container for health and health care
activities) are sensible and pragmatic, but they remain an
under-theorised and rarely explicit foci of attention. Current
evidence, in most settings and across the lifespan continuum,
suggests that concerted and universal health promotion reform
is still to be realised in nursing but that it is being worked
towards. It is hoped that the novel perspective of this article,
in linking all these contexts so that nurses view and practice
their health promotion across the whole gambit of both
linked-up settings and a linked-up lifespan continuum, will
help to broaden called for health promotion reform in
nursing and extend the health care repertoire of nurses.

Relevance to clinical practice

Where health promotion is often a contested concept in
nursing-related health promotion practice, theory and policy,
this article proposes a unique and original framework that
marries lifespan and settings-based health promotion. It is a
further attempt to clarify and situate health promotion in
nursing as a concerted and structured role and function.

Contributions
Study design: DW; data collection and analysis: DW and
manuscript preparation: DW.

Conflict of interest statement

The author declares that they have no conflict of interests.

 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 21832194

Clinical issues

A lifespan/settings-based framework for health promotion

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