Healthy settings: challenges to generating evidence of effectiveness.

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.