The concept of a "Health Promoting University" (HPU) has generated both interest and enthusiasm as universities face the challenge of addressing of college student health and how it impacts learning, both abroad and in the United States. The bases for this concept are three World Health Organization (WHO) public health initiatives: the 1977 Declaration of Alma-Ata, the strategy for "Health For All By The Year 2000", and the 1986 Ottawa Charter for Health Promotion. The focus of these three initiatives has led to "new" public health efforts which are ecological in nature and are based on "settings": the environments within which people live and work (Ashton, Tsouros, Dooris, Dowding, & Thompson, 2002). According to the Ottawa Charter for Health Promotion, "Health is created and lived by people within the settings of their everyday life; where they learn, work, play and love" (Dooris & Martin, 2002, p.17). This "settings" approach to public health was first systematized in 1987 with the WHO Healthy Cities project in Europe followed by other "settings" in Europe such as homes, schools, workplaces, hospitals, prisons and other environments (Tsouros, Thompson, Dooris, & Dowding, 1998).

Of interest to this article is the "setting" of the "university" having as its goal the development of a framework for a coordinated approach to health promotion for American university students. Universities in the 21st century are distinctive in the number of key roles they could play in the area of health promotion, roles that provide opportunities that affect the health and wellness of students, faculty and community members. First and foremost, a university is a center of learning and development where education, training and research take place. It is a center of creativity and innovation as well as a setting in which youth develop independence and learn life skills. A university is also a resource for, and a partner in, the well being of the local community. Finally, a university is a business--a business concerned with its image and its performance within a competitive market (Abercrombie, Gatrell, Thomas, Tsouros, Thompson, & Dowding, 1998).

These key and multifaceted roles provide the university opportunities to be an excellent "setting" for health promotion. However, there are also constraints to such an initiative. First of all is the issue of funding--rather than experiencing increases in funding, universities have instead suffered from funding cuts in recent years. As a result, class sizes have increased, as have faculty and staff workloads. Students are often faced with crowded classrooms, libraries and laboratories, receive less support from "stressed" and "stretched" faculty and student learning and development offices on campuses, face reductions in financial support and look forward to a more volatile and depressed job market (Abercrombie et. al., 1998). Additionally, university administrators often view the role of a university as one that addresses the learning and vocational needs of students--not their health needs. Some university administrators do recognize the link between health and learning and realize that the concept of a health promoting university as one that would appeal to parents as well.

Health Promoting Universities around the World

Globally, within several countries there are indeed universities actively engaging in health promoting university projects. The HPU "setting-based" approach has been thus far adopted at two universities in Great Britain: the University of Central Lancashire (Dooris, 1998) and Lancaster University (Dowding & Thompson, 1998). HPU projects at these universities reflect the collaborative approach they have taken to the development of a health promoting university. Several universities in China have also adopted the HPU concept on their campuses. The Chinese University of Hong Kong launched its Health Promoting University Initiative in 2000. A Health Promoting Universities project was also implemented in six Beijing area universities Xiangyang, Lan, Xueping, Tao, Yuzhen, & Jagusztyn, 2003).

In Canada, the approach to university student health that is has been applied to the development of an HPU is the Ecological Model of Health Behavior, first introduced in 1988 (McLeroy, Bibean, Steckler, & Glanz, 1988). Based on the ecological foundations of health promotion, it was designed to guide behavioral interventions and emphasizes the environmental and policy contexts of behavior while incorporating social and psychological influences as well. It proposes that behavior has multiple levels of influence: intrapersonal (biological and psychological), interpersonal (social, cultural), organizational, community, physical environment, and policy factors all play a role as part of the "environment" which influences health behavior. The ecological model also maintains that the influences on behavior interact across these levels and that, in order to be most effective in changing behavior, multilevel interventions should be used. Sallis, Owen and Fisher (2008) propose that ecological models are most powerful when they are behavior-specific.

Creating Health Promoting Universities in the United States

Differences in university systems throughout the world require somewhat different approaches. While the concept of a "health promoting university" as seen in the United Kingdom and in China has not been universally adopted in North America, this is not to say that American colleges/universities are not involved in health promotion efforts on behalf of their students, nor that the WHO public health initiatives have not been promoted.

One of the leading voices for student affairs administration, policy, and practice, National Association of Student Personnel Administrators (NASPA) has weighed in on the health in higher education issue through its Health in Higher Education Knowledge Community (NASPA, 2008) which outlines a framework for health promotion planning that utilizes the socio-ecological model, the model of choice for addressing issues such as violence prevention, college student drinking, and other issues embedded within cultural norms. Further support for advancing student learning by addressing the health of university students is found in the Council on the Advancement of Standards in Higher Education, through its Professional Standards for Higher Education which focuses on the available resources in a systemic way to address the primary prevention needs of the student population as they contribute to the learning mission of the institution (Dean, 2006).

Many American universities are striving to improve student health through the adoption of the American College Health Association's (ACHA) document Healthy Campus 2020 which provides a model for developing student health related objectives and prioritizing interventions in dealing with these issues identified through assessment. Another tool, the American College Health Association-National College Health Assessment (ACHA-NCHA-II) provides universities with an excellent tool to help understand the health of students as well as their health risk behaviors. Institutions of higher learning can use the results to analyze, prioritize and address the health problems students at individual universities face. The ACHA-NCHA-II also provides an excellent tool with which an individual university can compare its students with those of the nation as a whole. Unfortunately, while a national picture is provided by such surveys it is not a complete picture as not all universities participate in the survey on a yearly basis. But individual universities can certainly benefit from the data it provides.

Individual institutions of higher education that participate in the ACHA-NCHA-II receive tabulated results regarding their student populations which allows for targeted program planning and intervention that can be tailored to the specific needs of the particular student population. Results reveal that the health of American college/university students and their academic performance is being affected by a variety of factors. Behavioral patterns represent the single most prominent domain of influence over health prospects for college students (American College Health Association, 2009). The strategies students choose to cope with stress, relationships, sleep difficulties, concerns for family members and friends, deaths of loved ones and feelings related to depression and anxiety are frequently inadequate: they consume alcohol, smoke cigarettes, make poor choices in regard to diet, physical activity, and sexual behavior. These behavioral choices can lead to physical ailments, which further impact academic performance.

However, while infectious diseases and other physical ailments continue to be reported, mental health and social health issues are at the forefront when it comes to impediments to learning and living a quality life. College student health status and behavior are affected also by social circumstances and environmental conditions. Interpersonal linkages, or lack thereof, and cultural influences affect students as to hazards existing in the places where students live, study and work. While toxic agents (pollutants and products) are generally well-controlled by university policies, other environmental issues that affect student health do not always receive the recognition required when it comes to a university that is "health promoting". Physical education courses are not required, parking structures and shuttle services encourage inactivity, and the "fast food industry" is increasingly part of dining offerings at universities (J. Grizzell, personal communication, January 09, 2008).

Since student health appears to be multi-factorial the best way to address it requires a coordinated effort. Coordination of efforts by all the campus entities associated with the many factors affecting student health and academic performance is key. Making sure that the efforts being provided across a campus are linked and that the various campus units charged with improving a particular aspect of the health and well being of students work together is very important. If a university's mission of enhancing learning and knowledge is to be achieved, a "health promotion agenda" must be implemented. Attention should be drawn to policy opportunities for promoting the health of the student population (American College Health Association, 2009). As understanding and awareness of effective health promotion tools and interventions increases, broader leadership is necessary to gather the determination to change from a clinical approach to disease prevention and health promotion. Thought leaders, vice presidents and deans in particular, must also become engaged in the discussion and debate on how to best focus on promoting the health of university students.

Creating a Health Promoting University--A Suggested Framework

In order to ensure that a college/university is a health promoting one, where efforts are coordinated, it is suggested that the following six components are crucial to its development.

1. Administrative support and commitment within a senior administrative unit

Having a top administrative officer (e.g., Vice-President for Student Affairs) engaged in the oversight of a coordinated approach to campus health as a strong advocate is critical. Ideally it should be an individual who reports directly to the University President. What is important is that the administrative officer is committed to assuring the campus is a learning, living and working environment that is health enhancing and motivates students to address their personal health and well being as well as their academic needs. This administrative officer will understand the link between all the dimensions of health: the physical, social, intellectual, emotional, environmental, and spiritual as well as understand and advocate for needed health promoting policies.

2. The Appointment of a Cross-campus Steering Group and a Campus Coordinator to facilitate collaborative planning for student health

An organizational structure specifying functional relationships among various components of the institution, including the total college health program, is the responsibility of the institution and its governance body. To facilitate collaborative planning for student health, the proposed framework suggests that representatives from all the offices that are involved with some dimension of student health and wellness across a university campus be included in a Cross-campus Steering Group with representatives from a variety of offices and groups on the university campus along with as much student representation as possible (e.g., the health service, counseling, recreation, residence halls, commuter services, food services, new student orientation, environmental health and safety, fraternity, sorority and service clubs, disability support services, career center, multicultural and diversity office, academic support services, student retention services and student government). To oversee the work of this cross campus steering group, and to facilitate the coordination of the steering group's efforts, a full or parttime (at least 50%) Campus Coordinator who oversees and facilitates the execution of the activities of the Cross--campus Steering Group should be appointed as a visible symbol of the university's commitment to becoming a "health promoting university".

3. The development of a plan for continuous improvement of all the dimensions of student health and wellness

As noted earlier, the daily choices they make with respect to coping strategies in confronting stress, refusal behaviors around cigarette smoking and substance abuse, diet and physical activity are the leading factors determining current and future health as well as academic success. Inadequately dealing with stress, relationships, sleep difficulties, concerns for family members and friends, deaths of loved ones and feelings related to depression/anxiety are the most frequent causes of poor academic performance. These behaviors should be addressed in a plan based on data provided by surveys such as the ACHA-NCHA II or others created by individual universities. Evaluation of the plan's health promotion efforts should be continuous so efforts that are effective can continue to be implemented while those that are not effective can be improved upon.

4. The involvement of students in planning and implementing health promotion activities for the campus and surrounding community

The goals and the organization of a Health Promoting University should be focused not only on meeting the health needs of the students, but also engaging students in the planning and implementing of health promotion programming for themselves as well as for the surrounding community. Students should be involved in planning and leading health promotion initiatives. Administratively this could occur with student membership on the HPU Cross Campus Steering Committee. The development of a cross-campus Health Promotion Student Task Force consisting of representatives from student organizations involved in health related areas (e.g., service clubs, honoraries, student clubs, service learning requirements focusing on health issues, and other student driven efforts that focus on health) would be very useful. These collaborative experiences on the undergraduate level will help develop students' leadership and advocacy skills and will provide a better understanding of the value of collaboration among disciplines to achieve specific health promotion goals.

5. The creation of a healthy learning, living and working environment that helps improve academic performance and student retention

Mission, vision, and values statements demonstrate an institution's commitment to student health and set the tone for building a healthy campus community. Post-secondary institutions have a responsibility to create an environment that is safe and supportive for all students. Mechanisms for a healthy campus environment include establishing a task force, enforcing a code of student conduct and nondiscrimination policies, allocating funding for health promotion programs, and using environmental interventions.

Environmental interventions include campus housing opportunities that support healthy lifestyle choices, such as "wellness halls" or substance-free housing; condom availability; and alcohol-free social events. Broad environmental themes could include promoting access to and use of university grounds and facilities; developing and implementing projects to minimize waste and to promote recycling; instituting "tobacco-free" campuses; developing environmental policies that encourage a "green" campus and that attend to issues of energy use, transportation, parking, and noise.

6. The provision of professional development opportunities for staff, faculty, administrators and student health promotion leaders.

Professional development provides opportunities for participants to identify areas for improvement, learn about and use proven practices, solve problems, develop skills, and reflect on and practice new strategies. It is an important component of the framework of an HPU and requires funding and technical support. Professional development is the key to helping faculty, staff and administrators understand their role in building a healthy campus. Knowledge of the student services that are available (e.g.; health services, counseling center, learning center, HIV testing, etc.), how and to whom to refer students as well as understanding of their role in health promotion efforts are all extremely important in regard to promoting a supportive and nurturing learning environment and need to be provided through various professional development opportunities. Also necessary are professional development activities that can provide an understanding of issues related to diversity and cross-cultural differences.

A framework for a health promoting university such as the one proposed here, one that is based on the theory and experiences of the countries that have adopted this approach but which also incorporates the uniqueness of American colleges/ universities as well as its students and their health needs, could be of great use in American colleges and universities. While health promotion activities are indeed occurring on many campuses, they are often fragmented with various offices providing isolated efforts. By working together utilizing a coordinated, systematic approach that is supported by the administration and provides for a continuous improvement process, university "settings" can bring both health and academic benefits to students.

References

Abercrombie, N., Gatrell, T., Thomas, C., Tsouros, A., Thompson, J., Dooris, M., & Dowding, G. (1998). Universities and health in the twenty-first century. In Health promoting universities concept: Experience and framework for action. Copenhagen: World Health Organization.

American College Health Association (2009). American college health association: National college health assessment spring 2008 reference group data report (abridged). Journal of American College Health, 57(5), 477-488.

Ashton, J., Tsouros, A., Dooris, M., Dowding, G., & Thompson, J. (1998). The historical shift in public health. In Health promoting universities concept: Experience and framework for action. Copenhagen: World Health Organization.

Dean, L. (2006). CAS professional standards for higher education (6th ed.). Washington, DC: Council for the advancement of standards in Higher Education.

Dooris, M. (1998). The university as a setting for sustainable health: University of Central Lancashire. In Health promoting universities concept: Experience and framework for action. Copenhagen: World Health Organization.

Dooris, M. & Martin, E. (2002) The health promoting university: from idea to implementation. Promotion and Education, 9(Supplement 1), 16-19.

Dowding, G. & Thompson, J. (1998). Embracing organization development for health promotion in higher education: Lancaster University. In Health promoting universities concept: Experience and framework for action. Copenhagen: World Health Organization.

McLeroy, K., Bibean, D., Steckler, A., & Glanz, K. (1988). An ecological perspective on health promotion programs. Health Education Quarterly, 15(4), 351-357.

NASPA--Student Affairs Administration in Higher Education. (2008). NASPA health in higher education knowledge community mission. Retrieved from http://naspa.org/kc/ hhekc/mission.cfm

Sallis, J.F., Owen, N., & Fisher, E. (2008). Health behavior and health education: Theory, research and practice. San Francisco: Jossey-Bass.

Tsouros, A., Thompson, J., Dooris, M., & Dowding, G. (1998). Health promoting universities concept: Experience and framework for action. Copenhagen: World Health Organization.

Xiangyang T., Lan Z., Xueping M., Tao, Z., Yuzhen, S., & Jagusztyn, M. (2003). Beijing health promoting universities: practice and evaluation. Health Promotion International, 18(2), 107-113.

Chrystyna Kosarchyn, PhD, CHES, Professor of Health Education, Dept. of Health, Athletic Training, Recreation and Kinesiology, Longwood University