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Health & Place 26 (2014) 161170

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Health & Place

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Review Essay

Online social networking sitesa novel setting for health promotion?

Julika Loss n, Verena Lindacher, Janina Curbach
Medical Sociology, University of Regensburg, Franz-Josef-Strauss-Allee 11, D-93053 Regensburg, Germany

art ic l e i nf o

a b s t r a c t

Article history:
Received 25 July 2013
Received in revised form
18 November 2013
Accepted 17 December 2013
Available online 25 December 2013

Among adolescents, online social networking sites (SNS) such as Facebook are popular platforms for
social interaction and may therefore be considered as novel settings0 that could be exploited for health
promotion. In this article, we examine the relevant denitions in health promotion and literature in
order to analyze whether key characteristics of settings for health promotion and the socio-ecological
settings approach can be transferred to SNS. As many of our daily activities have shifted to cyberspace,
we argue that online social interaction may gain more importance than geographic closeness for dening
a setting. While exposition to positive references to risk behavior by peers may render the SNS
environment detrimental to health, SNS may allow people to create their own content and therefore
foster participation. However, those health promotion projects delivered on SNS up until today solely
relied on health education directed at end users. It remains unclear how health promotion on SNS can
meet other requirements of the settings approach (e.g. building partnerships, changing the environment). As yet, one should be cautious in terming SNS a setting.
& 2013 Elsevier Ltd. All rights reserved.

Keywords:
Social media
Internet
Facebook
Settings approach
Healthy settings

1. Introduction
Health is created and lived by people within the settings of their
everyday life; where they learn, work, play, and love. This famous
dictum of the Ottawa Charta, published by the World Health
Organization (WHO) (1986) is an early basis of the settingsbased approach to health promotion. More than two decades later,
the settings approach has become rmly integrated within international health promotion theory, policy, and practice. A settings
approach views the physical, organizational, and social contexts in
which people are found as the objects of intervention (Poland
et al., 2009). Other than traditional prevention strategies, which
are directed at an individual0 s behavior, the settings approach
endorses a socio-ecological model of health and aims to integrate
a commitment to health within the structures and processes of
social systems. A plethora of health promotion programs and
networks oriented to such settings have emerged, covering, above
all, work sites, communities and schools. The Healthy Cities
network is probably the best-known international example of
the WHO healthy settings initiative (Dooris, 2004). The settings
approach has also expanded to include other types of settings such
as islands, universities, and prisons (Green et al., 2000; Poland
et al., 2009). Within the last years, however, a further site has
evolved in which people learn, work, play and love: the Internet,

Corresponding author. Tel.: 49 941 944 5220; fax: 49 941 944 5202.
E-mail address: julika.loss@ukr.de (J. Loss).

1353-8292/$ - see front matter & 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.healthplace.2013.12.012

and in particular the online social networking sites (SNS) such as

Facebook or MySpace (Boyd and Ellison, 2007).
By today, the internet has reached near ubiquity and is
generally regarded as an indispensable communication tool
throughout the developed world (Bennett and Glasgow, 2009).
The standard on which the internet is now based is known as
Web 2.0: web applications allow end users to interact and
collaborate as content creators, rather than the one-directional
information on relatively static Web 1.0 websites dated pre-2004
(Centre for Health Promotion and Women0 s and Children0 s Health
Network, 2012; Gold et al., 2012). SNS such as Facebook, MySpace,
Google , or LinkedIn, are part of the Web 2.0 realm; they allow
online information sharing and interactivity among users. The
primary feature of these sites is that users upload personal details
about themselves to their own page (prole) and then link their
website to the pages of their friends (Freeman and Chapman,
2008). Thus these sites allow individuals to maintain, form and
visualize social networks (Boyd and Ellison, 2007). Over the last
years, we have seen a tremendous growth in usage and popularity
of these sites among ever younger users (Freeman and Chapman,
2008; Gold et al., 2012). 72% of adult internet users join in SNS
(Brenner and Smith, 2013). In 2012, Facebook had more than 900
million members world-wide, 187 million of which lived in the
European Union (Miniwatts Marketing Group, 2012a). In the US,
women are slightly more likely than men to be active SNS users
(women: 74%; men: 71%). The use of SNS is especially popular in
the younger generation, but becomes increasingly relevant for
older age groups as well: 89% of internet users aged 1829 are SNS
users, as are 78% of those aged 3049; 43% of Internet users older

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J. Loss et al. / Health & Place 26 (2014) 161170

than 65 have an active role in SNS. US data also show that all
education levels, ethnic groups and household income categories
are represented in SNS in similar shares (Brenner and Smith,
2013). Global data show, however, that in some world regions
Internet usage and hence SNS usage is marginal, especially on the
African continent (16%). In other regions like the Middle East, Latin
America and Asia, SNS usage varies between 27 and 42%
(Miniwatts Marketing Group, 2012b).
Over the last decade, the Internet has also been used to deliver
public health interventions across a wide range of conditions and
population segments (Bennett and Glasgow, 2009; Gold et al.,
2012). However, health interventions directed to the general
population (not to a certain patient group) have mainly used
traditional Web 1.0 channels, such as health education websites
(Bennett and Glasgow, 2009; Freeman and Chapman, 2008). In
contrast to the one-way information ow of Web 1.0 services, the
interactive element of SNS provides a more sophisticated channel
for health communication. SNS form an environment for social
interaction via the internet and thus might be seen as a special
kind of setting, as is illustrated in a compelling way in a recent
analysis: Imagine there is a centre that the vast majority of young
people go to most days of the week for several hours a day. Young
people at this centre are seeking health related and wellbeing
information, but there are no health promotion workers This
describes the current situation if we conceptualise the social media
environment as a setting.(Centre for Health Promotion and
Women0 s and Children0 s Health Network, 2012). Also other
authors call online SNS novel or virtual settings (Gold et al.,
2012; Green et al., 2000). However, whether SNS such as Facebook
can be conceptualized as settings at all has not been rigorously
examined yet. In addition, very little has been published about
how SNS, if understood as a setting, might be exploited for health
promotion interventions (Gold et al., 2012), and what special
setting characteristics need to be considered.
Therefore, in this article, we intended to
1. analyze whether features of SNS correspond to essential
characteristics of settings for health promotion0
2. examine how essential characteristics of the settings approach
to health promotion can be transferred to SNS

We will do this by identifying a range of key characteristics of

both a setting and the settings approach as they have been
promoted in corresponding health promotion denitions. For each
of these key features, we will then draw on the existing evidence
in the scientic literature in order to discuss if SNS qualify for

a setting for health promotion and if the settings approach may be

applicable to SNS. Based on the results of this list of setting
characteristics and health promotion evidence, we will conclude
by shortly discussing the arguments in support and against the
idea of SNS as novel settings for health promotion.
We are well aware that SNS are only one form of applications
provided by Web 2.0. Other social media technologies that are
highly popular as well include Internet forums, weblogs, wikis,
virtual game worlds, and podcasts, to name only a few. However,
we decided to focus exclusively on SNS. In order to analyze a form
of social media with regard to its potentially being a setting for
health promotion, it is important to comprehensively understand
the environment (i.e. the technical features that inuence the
interaction), the activities performed in this environment, the
norms and codes of conduct that have evolved within this context,
and the group of people using this form of media. These aspects
may vary substantially between different Web 2.0 applications,
a fact which would have rendered the analysis overly complex. We
mainly refer to SNS such as Facebook and MySpace, because most
information, research and evidence available apply to these
platforms.

2. Do characteristics of Settings for Health Promotion apply

to SNS?
The settings approach has its main roots in the Ottawa Charter
for Health Promotion, and has developed over the past 25 years to
become a key element of public health strategy. It has been
inuenced by ecological theory which holds that the individual0 s
functioning is mediated by behaviorenvironment interaction
(Green et al., 2000). Denitions for settings for health promotion
are abundant. We searched position papers, monographs/edited
books, and review articles that featured healthy settings, and
selected seven denitions which have proven to be of relevance
in the last decades0 discourses on settings in health promotion;
they stem from different years, different organizations, different
professions, and vary in breadth and dimension of the conceptualization of a setting, see Table 1.
The denitions of the WHO (as published in the Ottawa Charter
and the Health Promotion Glossary) are the core of almost all
denitions available; some descriptions extend the original denition, spell out some aspects in more detail or emphasize certain
criteria. We are well aware that the selected denitions do not
represent a complete collection, but believe that it is sound to limit
the number of denitions to be analyzed because (1) across these
denitions, a sufciently broad number of different, but repeatedly

Table 1
Setting for health promotion: Selected denitions and/or descriptions.
(1) A behavior setting is a place where most of the inhabitants can satisfy a number of personal motives, where they can achieve multiple satisfactions. (Barker, 1968)
(2) Health is created and lived by people within the settings of their everyday life; where they learn, work, play, and love. (World Health Organization, 1986)
(3) The place or social context in which people engage in daily activities in which environmental, organizational and personal factors interact to affect health and
wellbeing. A setting is also where people actively use and shape the environment and thus create or solve problems relating to health. Settings can normally be
identied as having physical boundaries, a range of people with dened roles, and an organizational structure. () Examples of settings include schools, work sites,
hospitals, villages and cities. (World Health Organization, 1998)
(4) Settings may be dened as spatial, temporal and cultural domains of face-to-face interaction in everyday-lifeA setting refers to a socially and culturally
dened geographic and physical area of factual social interaction, and a socially and culturally dened set of patterns of interactions to be performed while in the
setting. A setting represents a frame of face-to-face, social interaction among human beings, the meaning of which is socially and culturally shared within the
particular group of people being a part of the setting for a certain period of time. (Wenzel, 1997)
(5) Settings areorganizations that are accepted as a social entity due to their structure and assignment (These organizations) are a consciously co-ordinated
social entity with relatively distinct memberships, which works on a relatively constant foundation in order to achieve one or more goals. (Baric and Conrad, 1999)
(6) Settings can be conceptualized as both (a) physically bounded space-times in which people come together to perform specic tasks (usually oriented to goals
other than health) and (b) arenas of sustained interaction, with pre-existing structures, policies, characteristics, institutional values, and both formal and informal
social sanctions on behavior. (Green et al., 2000)
(7) The setting is a social context which is relatively permanent and of which its members have a consciousness. This context can be expressed by a formal
organization (e.g. school), regional situation (e.g. community), similar conditions of life (e.g. senior citizens) or common values and preferences (e.g. religion).0
(Bundeszentrale fr gesundheitliche Aufklrung, 2003).

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J. Loss et al. / Health & Place 26 (2014) 161170

named core features occurred, and (2) we experienced a conceptual saturation, i.e. no more new features were identied when
further denitions were analyzed, because these further denitions were mostly referring back to one of the denitions selected
before. The key features that are attributed to a setting for health
promotion throughout these various denitions are that a setting:

Offers social context and social interaction.

Is a geographical locus / has physical boundaries.
Is an integral part of everyday life.
Allows for the pursuit of various personal professional or
leisure time activities.
Displays policies and an organizational structure.
Is based on shared values, norms, sanctions and/or a code of
conduct.
Has an inuence on health and well-being.
Is permanent and/or consistent.

In the following paragraphs, we describe each of these characteristics and analyze whether it applies to SNS such as Facebook
or MySpace. For a summary, see Table 2.

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social environment just as well as the physical environment

(McLeroy et al., 1988).
Does this apply to SNS? SNS basically consist of connections
between users (Boyd and Ellison, 2007), information exchange,
and multidirectional conversations. People mainly use these platforms to (a) get to know people, (b) stay in contact with friends,
(c) share and discuss content and photographs with others
(Brandtzaeg and Heim, 2009; Joinson, 2008; Raacke and BondsRaacke, 2008; Urista et al., 2009). Young people also negotiate
intimate relationships online, including irting, breaking up, and
sexual encounters (Pascoe, 2011). In addition, SNS have also been
described to be used to bully and harass others (Daine et al., 2013).
Therefore, social interaction is a criterion that applies very well to
online social media although this interaction differs from
traditional face-to-face interactions. On SNS, people produce social
relationships and interpretations of reality only by exchanging
written information back and forth, whereas social interaction in
real life relies to a great extent on a much more immediate
exchange of nonverbal communicative signals.

2.2. Geographical locus and physical boundaries

2.1. Social interaction
About this characteristic. The terms social context or interaction can be considered as a core characteristic of a setting (Green
et al., 2000; Wenzel, 1997; World Health Organization, 1986,
1998). In the socio-ecological perspective, the environments that
shape human behavior and health include family, peer groups and

About this characteristic. Many, though not all, denitions dene

a setting as having physical boundaries (Green et al., 2000;
Wenzel, 1997; World Health Organization, 1998). The conception
of a spatially bounded place is also reected in the typical setting
examples that are mentioned throughout the health promotion
literature: schools, work places, communities, universities.

Table 2
Applicability of a setting0 s features to social networking sites (SNS).
Applicable to SNS?

Key feature

To be found in
denition no
(according to
Table 1)

Offering social context and

social interaction
Being a geographical locus /
having physical
boundaries
Being an integral part of
everyday life
Allowing pursuit of various
personal professional or
leisure time aims and
activities
Displaying an
organizational structure
and policies

(3), (4), (5), (6), (7) Yes; social interaction is a core characteristic of SNS
(1), (3), (4), (6)

(2), (3), (4)

(1), (2), (5), (6)

(3), (5), (6), (7)

(3), (4), (6), (7)

Basing on shared values,
norms, sanctions and/or a
code of conduct

Inuence on health and

well-being

(2), (3)

Permanence and/or
consistency

(5), (6), (7)

No; SNS have neither spatial nor virtual boundaries, but

allow their users to form their own individual social
network
Yes; the majority of young adults in developed countries
use SNS daily for 0.52 hrs
Yes; users are active co-creators of content, and pursue
activities such as staying in touch with friends, receiving
and sharing information, negotiating (intimate)
relationships
Yes;
 SNS have terms of use that govern the interaction of
its users
 SNS have common technical features which structure
and organize interaction, e.g. users0 proles, options
for posting text and photographs, and applica-tions
for giving feedback.
Partly; social sanctioning happens via (semi-)public
feedback, and result in SNS users striving to be compliant
to peer norms. Users employ strategies that present
themselves attractive to the audience (impression
management).
Partly; some environmental0 aspects of SNS may be
detrimental to their users0 health, e.g. online advertising of
legal drugs, other users0 positive display of risky / selfdestructive behavior, public display of negative feedback,
cyber bullying
Partly;
 Level of SNS: some SNS such as Facebook have long
been heavily used platforms for social interaction.
 Level of users: some groups and networks established
on SNS are remarkably stable.

Limitations

Interaction only consists of written/text- and imagebased communication

No other behavior than communication is possible in the

SNS. Risky health behavior that is normally targeted in
health promotion, e.g. substance abuse, is not taking
place in a SNS (just reported about)

There is little research on the values, norms, and roles

that shape the activities in SNS.

There is only scarce evidence whether the context of SNS

affects the health of its users.

 Level of SNS: In general, use and popularity of SNS are

dynamic and ever-changing processes.
 Level of users: many networks undergo rapid changes

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J. Loss et al. / Health & Place 26 (2014) 161170

Does this apply to SNS? If this common notion was followed

strictly, SNS would not qualify as a setting0 . However, there are hints
that geographically dened spaces are not a sine qua non for a
setting. Indeed, some health promotion initiatives explicitly address
the fact that geographic mobility and commuting has become
integral part of our everyday life: For example, Collins and Kearns
(2001) documented the negative health effects of trafc congestion
and trafc injuries around New Zealand0 s largest primary school and
identify the need for health promotion to address the issue of safe
traveling to and from the school setting (2001). Apart from this
increasing importance of geographical mobility in between settings,
according to Rosenbrock, a community of values or similarity of life
conditions may function as a substitute for a formal, geographically
bound organization (Bundeszentrale fr gesundheitliche Aufklrung,
2003). Also Chappell et al., 2006 put forward an alternative
conceptualization of community in health promotion, in which
relational elements or shared attributes can replace geographic
proximity (2006). In fact, the last decade0 s shift of many of our
working and living conditions to the cyberspace may render it
necessary to re-dene the terms of place and environment,
because they may be perceived differently today as in the 1980s
when the settings approach was rst promoted. Green et al. point
out that the locatedness of traditionally spatially well-dened
settings such as work and school0 begin to disintegrate, as people
work from home, engage in distance education etc. (2000). The
greater challenge, though, is the fact that SNS do not only lack
physical boundaries, but also virtual boundaries. SNS are not a x,
closed group of individuals registered for an online community, but
each user has his or her own network of friends that he or she is
sharing his or her information with. The average Facebook user is
reported to have 190 connections (Ugander et al., 2011), and the
scope of friends may be widening or changing every day. On the
other hand, it is a common phenomenon that groups of individuals
who are virtually interconnected form a social group in the real
ofine world as well, e.g. students of a certain study program of a
certain town (Boyd and Ellison, 2007).
2.3. Integral part of everyday life
About this characteristic: Some denitions, especially those issued
by the WHO, refer to the setting as being a platform for daily
activities (Wenzel, 1997; World Health Organization, 1986, 1998).
Does this apply to SNS? This characteristic has become true for
SNS for large populations in developed countries, especially young
people. For many of us, Facebook has become a part of daily life
(Cassidy, 2012). This corresponds to results from many surveys.
7788% of 1419-year-olds in Germany use Facebook (Busemann
and Gscheidle, 2012; Ebert et al., 2011).Users of SNS usually log in
daily, and spend an average of 0.52 h a day communicating on
the respective site (Cassidy, 2012; Hargittai and Hsieh, 2010;
Joinson, 2008; Raacke and Bonds-Raacke, 2008).
2.4. Pursuit of various personal tasks, activities, motives
About this characteristic: According to many denitions, individuals play an active role in a setting by engaging in personal
activities (Baric and Conrad, 1999; Barker, 1968; Green et al., 2000;
Poland, 1998). The Ottawa Charter names examples for these
activities: learn, work, play, love (World Health Organization,
1986). The activities may be directed at gaining satisfaction, or
related to a personal task or goal.
Does this apply to SNS? Web 2.0. allows users to generate and
distribute information, and therefore actively pursuing activities
and fullling tasks. The main activities pursued on SNS are apart
from organizing for real life activities getting to know people,
staying in touch with friends, receiving, sharing and discussing

information, and increasing one0 s popularity (Joinson, 2008;

Raacke and Bonds-Raacke, 2008; Urista et al., 2009). More passive
motives are named as well, e.g. monitoring the life and activities of
others (Brandtzaeg and Heim, 2009). Whereas the activities
pursued in SNS may be manifold, there is one limitation: all these
activities consist of communication. No other behavior than
communication is possible in the SNS. Individuals do not smoke,
drink or exercise in Facebook; they might just tell their friends on
Facebook that they smoked, drank, or exercised. This important
characteristic needs to be considered when identifying the personal behaviors that can be targeted if SNS were used for health
promotion interventions.
2.5. Organizational structure, norms, codes of conduct
About this characteristic: Almost all denitions of a setting name the
constitutive criterion of organizational structures and/or pre-existing
policies (Green et al., 2000; Poland, 1998; World Health Organization,
1998). Settings are co-ordinated social entities0 (Baric and Conrad,
1999) with dened roles, institutionalized values and social norms,
and both formal and informal social sanctions on behavior (Green
et al., 2000; Poland, 1998; World Health Organization, 1998).
Does this apply to SNS? Every SNS has its own applications and
rules that shape the possible interactions (and thereby the codes
of conduct that may evolve). SNS usually publish detailed policies
(e.g. terms of use), which govern the interaction of its users by
asking them to make certain commitments e.g. relating to registration, content sharing, privacy, safety, protection of (copy)rights
or advertisements. In addition, almost all SNS dispose of similar
technical features that can be understood as their organizational
structure. The backbone of a SNS consists of visible individual
proles of its users. SNS also encourage their users to continuously
post messages and photographs on their proles, e.g. describing
what they are currently doing (Boyd and Ellison, 2007). Facebook
or MySpace proles thus serve as a stage on which users can make
(semi-)public presentations of themselves. Users may strive to
portray themselves in a positive light (Zywica and Danowski,
2008) and therefore employ strategies that assist in presenting
themselves as attractive to the audience, known as impression
management in social psychology (Goffman, 1959; Rosenberg and
Egbert, 2011). Since this self-image is subject to constant sanctioning via public feedback, it is important to the SNS user to be
perceived as compliant to peer norms (Loss et al., 2013). The like
button, a Facebook feature, is an organizational component that
may enhance this process of social sanctioning. With the click of
the like button referring to a report or photograph, Facebook
users indicate approval in a quick and easy form of social
interaction (Wilson et al., 2012). The number of a user0 s friends0
clicks on the like button is publicly displayed on one0 s prole
(x people like this), a feature that increases social pressure for
everyone to join a competition for popularity (Zhao et al., 2008).
However, we only just begin to understand the norms, sanctions
and codes of conduct that may shape the activities in SNS. It is also
noteworthy that some authors describe SNS to be quintessentially
commercial platforms, as site owners make substantial prots
through the accessing of commercially branded products and
services, and by selling user data and advertising space to
commercial interests. The structural characteristics of SNS, i.e.
sharing of content, interactivity and virtual relationships, provide
new vehicles for marketing of products damaging to health, e.g.
alcohol (McCreanor et al., 2013), see also 2.6.
2.6. Inuence on health and well-being
About this characteristic: The WHO describes a setting as the
place or social context in which environmental, organizational

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J. Loss et al. / Health & Place 26 (2014) 161170

and personal factors interact to affect health and wellbeing.

(1998). If there was no link between the setting and the health
(behavior) of its members, it would be useless to change the
setting0 s environment, a core concept of health promotion.
Does this apply to SNS? There is only scarce evidence yet on how
the social or organizational context of sites such as Facebook
affects the health of its users. Social media use as such, as it
normally includes sedentary behavior in front of computers or
smartphones, may increase physical inactivity. Besides this
obvious tangible health effect, we identify the following environmental aspects within the communication processes of SNS that
may have an impact on the health (behavior) of their users:
1. Commercial marketing: Young people are exposed to a huge
amount of advertising online, e.g. videos for tobacco brands,
alcohol beverages and fast food restaurants. Alcohol brands set
up their own Facebook sites that have been shown to have
millions of friends, develop applications (e.g. texting a drink to
a friend) and activities such as interactive games and competitions. In addition, they post statements on SNS that work
to normalize alcohol in the everyday life of SNS users. Key
features of alcohol marketing include the blurring of usergenerated material and brand promotion. Research on social
media marketing, however, still remains in a developmental
stage (McCreanor et al., 2013; Nicholls, 2012), and there is very
limited research on the effect that this advertising has on
young people0 s risk behavior and public health outcomes
(Centre for Health Promotion and Women0 s and Children0 s
Health Network, 2012; McCreanor et al., 2013).
2. Display of risk behavior: References to alcohol or substance use,
unhealthy eating or sexual behavior are prevalent among
adolescents0 MySpace and Facebook proles (Egan and
Moreno, 2011; Loss et al., 2013; Moreno et al., 2010). Adolescents who observe SNS friends engaging in risk behavior
without experiencing negative consequences may be more
likely to adopt the behaviors portrayed (Moreno et al., 2010).
SNS references may be particularly potent inuences because
they are created and displayed by peers. Moreno et al. found
that on U.S.-American MySpace proles, only 2% of reports on
alcohol drinking referred to negative consequences such as
hangovers (Moreno et al., 2010). Also a German study implies
that due to the public nature of the communication, young
people utilize their reports about risk behavior (e.g. consumption of alcohol and unhealthy food) as a form of positive selfpresentation; risk behavior was always portrayed as a funny,
sociable and/or admirable activity (Loss et al., 2013). The health
of SNS users may be challenged by interaction on SNS since
their engagement in online self-presentation, fostered by like
buttons and other feedback options, blanks out any critical
assessments of risky health behavior. This may play a role in
normalizing risk behavior within young people0 s lives, contributing to intoxigenic environments on SNS (McCreanor et al.,
2013). Some social media platforms even actively promote
dangerous or self-destructive behavior, e.g. by sharing selfharm techniques or supporting anorectic eating disorders. SNS
like Facebook appear to be a relevant channel for young
females suffering from anorexia nervosa to exchange diseaserelated ideas. However, this explicit promotion of anti-health
behavior can mainly be found on specic internet forums or
groups, less in normal SNS communication (Daine et al., 2013;
Teufel et al., 2013).
3. Public display of interpersonal feedback, cyber-bullying: An
environmental structure of SNS that can be linked to possible
health effects is the publicly visible interpersonal feedback to a
friend0 s post (e.g. comments, or clicks on the like button).
There are hints in the literature that public feedback on an

165

individual0 s actions or messages is a predictor of self-esteem

and well-being. For adolescents who predominantly received
negative feedback on their proles, the use of SNS had negative
effects on their well-being (Valkenburg et al., 2006). In the
worst case, SNS can be used to bully or harass peers. There is
increasing evidence that cyber-bullying via email, SNS or other
media has a signicant inuence on self-harm and may even
increase rates of attempted suicide (Daine et al., 2013).

2.7. Permanence/sustainability
About this characteristic: Some denitions declare permanence
or sustainability as a constitutive characteristic of a setting (Baric
and Conrad, 1999; Bundeszentrale fr gesundheitliche Aufklrung,
2003; Green et al., 2000). This is important for interventions to
have the chance to achieve long-term results and sustainably
improve the setting0 s environment and the health of its members.
Does this apply to SNS? Discussing the aspect of permanence for
SNS is complex. Use and popularity of social media platforms do
vary; new platforms are created and trends are changing rapidly.
However, sites such as Facebook and MySpace have remained
strong leaders in the eld for about 10 years already (Centre for
Health Promotion and Women0 s and Children0 s Health Network,
2012). The medium of SNS as such can be expected to stay a
relevant communication platform for years to come. If, in terms of
permanence, the group level of users is considered, some SNS
groups are remarkably stable, whereas others are characterized by
rapid dynamics and changes.

3. Can core features of the Settings approach be transferred

to SNS?
In health promotion practice, the term settings approach is
used to describe a variety of different intervention strategies. In
some cases, a settings approach is designed as using geographical
sites for health education, such as lifestyle modication programming in certain settings. Others focus on a meaningful shift of the
organizational and social environment, bringing about new policies and structural change (Dooris, 2004; Wenzel, 1997; Whitelaw
et al., 2001). Ideally, health promotion initiatives using a settings
approach endorse both promoting individual health behavior as
well as changing the structural or physical characteristics of the
setting itself. For example, a public health campaign on the health
risks of extensive sun exposure in schools may include educating
children on proper sun protecting behavior as well as providing a
supportive built environment with sun shades in the school yard
(Collins et al., 2006). On the conceptual level, however, the
literature suggests that a certain degree of consensus of the core
features of the settings approach to health promotion exist
(Dooris, 2006; Whitelaw et al., 2001): it is based on a socioecological view of health, which holds that health promotion seeks
to empower people by giving them control over the behavioral
and/or environmental determinants of their health, and thus
moves beyond using the setting as a mere route for distributing
educational materials (Dooris, 2004; Green et al., 2000; King,
1998). This corresponds to the original concept of Healthy Settings,
the approach that was put forward by the World Health
Organization (2013). We searched position papers, monographs/
edited books, and review articles that featured the settings
approach in health promotion in general. Again, the essential
description can be attributed to the World Health Organization
(2013); in addition, we analyzed 4 further denitions or descriptions (Dooris, 2004; King, 1998; Poland et al., 2009; Whitelaw

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Table 3
Settings approach in health promotion: Selected denitions and/or descriptions.

(1) A settings approach to health promotion organizes it in relation to the environment in which people live, work, and play [it] views the physical, organizational
and social contexts in which people are found as the objects of inquiry and intervention, and not just the people contained in or dened by that setting. (Poland et al.,
2009)
(2) The settings-based approaches to health promotion involve a holistic and multi-disciplinary method which integrates action across risk factors. Healthy Settings
key principles include community participation, partnership, empowerment and equity Actions often involve some level of organizational development,
including changes to the physical environment or to the organizational structure, administration and management. Settings can also be used to promote health
as they are vehicles to reach individuals, to gain access to services, and to synergistically bring together the interactions throughout the wider community. (World
Health Organization, 2013)
(3) A number of key features are accepted as central to [setting] activity: as well as acting to develop personal competencies, there is a desire to act in various ways on
policies, re-shape environments, build partnerships, bring about sustainable change through participation, and develop empowerment and ownership of change
throughout the setting (Whitelaw et al., 2001)
(4) The settings approach involves addressing the range of physical, social, organizational and cultural factors inuencing health in an environment. Settings are
therefore more than convenient locations for reaching target groups; they are also social systems that can support health and provide avenues for changing social
systems, not just individuals. The outcomes include changes in environments, policy, skills and organizational processes, as well as changes related to specic
health problems. (King, 1998)
(5) A common way of understanding the settings approach is by separating out three key elements: creating supportive and healthy working and living environments;
integrating health promotion into the daily activities of the setting; anddeveloping links with other settings and with the wider community. It is also clear that
the approach has a number of particular characteristics
1.
The approach is multidisciplinary, rooted in a socio-ecological understanding of health and uses whole system thinking and working
2.
It is underpinned by core values drawn from Health 21, the Ottawa Charter., and Agenda 21.
3.
It combines high-visibility project work with long-term organizational development and change.
4.
It seeks to balance top-down managerial and/or political commitment with bottom-up engagement and empowerment.
5.
It is driven by both public health and organizational agendasaction for health must help deliver the core business of the setting. (Dooris, 2004)

et al., 2001) which are cited and re-iterated throughout the health
promotion literature (see Table 3).
Across these denitions, we identied the following key
features of a settings approach to health promotion:
Addressing individuals within the setting and building upon
their capacities/skills.
Changing the physical environment, organizational and social
structure and/or policies.
Building partnerships within the setting, developing links to
other settings or to the wider community.
Seeking participation of setting members and employing strategies to empower them.
In the following paragraphs, we briey explain each of these
characteristics and discuss how it might be transferred to health
promotion interventions delivered on SNS (see also Table 4).
3.1. Addressing individuals within the setting and building upon
their capacities/skills
About this characteristic: Although settings are more than
convenient locations for reaching target groups (King, 1998),
addressing and informing individuals within a setting is usually
part of the health promotion approach. The settings approach may
not primarily intend to change behaviors, but addresses underlying competencies and skills of the setting0 s members (King,
1998; Poland et al., 2009; Whitelaw et al., 2001).
Can this be transferred to SNS? In the literature describing the
potential of SNS for health promotion, new social media are
predominantly meant to be used for disseminating health messages among broad audiences with the aim of education and
behavior change (Apatu et al., 2013; Korda and Itani, 2013;
Thackeray et al., 2008). However, the special characteristics of
SNS may allow to move beyond being only another output
channel0 (Thackeray et al., 2012) when addressing individuals
Interaction with target group: Social media offer the opportunity
to initiate an ongoing exchange of ideas and experiences about
certain health concerns or preventive services among the
SNS members (Thackeray et al., 2012). Examples of health

promotion interventions that were delivered on Facebook (e.g.

on HIV prevention or sexual health), focused on not only
broadcasting information, but also on interacting and engaging
with the target group (Bull et al., 2011; Gold et al., 2012):
two-way interaction [is] an important feature of health
promotion interventions in this medium (Gold et al., 2012).
Through this active engagement, interventions on SNS may
help building personal skills, e.g. in health literacy, or health
care-related interactions (Centre for Health Promotion and
Women0 s and Children0 s Health Network, 2012; Korda and
Itani, 2013).
Word of mouth: SNS encourage users to share content and thus
may foster word of mouth communication (Korda and Itani,
2013; Thackeray et al., 2012), i.e. the act of consumers providing information to other consumers(Freeman and Chapman,
2008). On SNS, users can recommend a certain site or link, e.g. a
preventive video on YouTube, to their friends and may thus
become champions for certain causes (Thackeray et al., 2012). If
health content is passed along to more and more friends, this
can result in an exponential spread among users (similar to
viral marketing) the greatest success one can have on a
social networking site (Gold et al., 2012). Some videos promoting health behavior have managed to go viral, e.g. the emotional video spot Embrace Life0 by Sussex Safer Roads, although
these are exceptions (Gold et al., 2011). On the other hand,
public health experts warn that health messages might become
distorted when they are distributed and changed by social
media users (Jones, 2011).
Those few published interventions addressing individuals in
order to change health behavior (or other behavior, e.g. reducing
energy consumption) through SNS were all set up in a similar way:
rst, the researchers created a special site on Facebook or MySpace
in one case using ctional characters on which they posted
content on the (health) issue addressed, e.g. regular updates and
videos (Bull et al., 2011; Gold et al., 2012; Mankoff et al., 2007).
Second, the intervention was promoted and participants recruited,
mainly in the ofine world by utilizing traditional methods of
promotion, such as approaching youth on community college
campuses, and/or advertising in local city or college newspapers.
The participants were requested to become a fan of the health

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167

Table 4
Transferability of the settings approach0 s features to social networking sites (SNS).
Key feature

To be found in
denition no
(according to
Table 3)

Addressing individuals (1), (2), (3), (4)

within the setting
and building upon
their capacities/skills

Transferable to SNS?

Experience from practice

Yes; SNS can be a tool to

reach and educate certain
audiences and
engage users in sharing and
distributing health messages (word
of mouth)

Sample projects mainly focused on

broadcasting information plus
interacting with the target group (twoway communication)

Limitations

In order to reach individuals via SNS,

one needs their consent to be part of
their personal network; recruitment
in the ofine world seems necessary
health messages might get distorted
when distributed by SNS users

Changing the physical

environment,
organizational and
social structure and/
or policies

(1), (2), (3), (4),

(5)

Unclear. Approaches might need to

One project motivated MySpace users to There is a lack of reports on how the
environment0 and organizational
target
eliminate references to risky sexual
behavior or substance abuse.
display of risk behavior
features of SNS can be changed for
technical applications and social
better health.
norms that enhance positive
presentation of risk behavior
sanctions by public feedback options

Building partnerships
within the setting,
developing links to
other settings or to
the wider
community

(2), (3), (5)

Unclear. Public or private organizations

with a health focus (e.g. driving safety
groups) that have their own SNS
presence may be a partner for health
promotion projects.

Seeking participation
of setting members
and employing
strategies to
empower them

(2), (3), (5)

Partly;
As SNS users actively create and
disseminate content, projects can
use SNS as a tool for participation
and engagement.
SNS can link people with common
interests and could be used to
organize online and ofine activities
and/or protests on health issues,
thus fostering users0 empowerment

It is difcult to identify stakeholders

or key players on SNS that could
serve as partners.
The decision-makers, i.e. the
corporations that own the SNS
websites, will be hard to reach
So far, the participation achieved by
health promotion projects on SNS is
limited to consulting with the users

Two-way interaction alone does not

comply with participation as
dened by health promotion theory,
as it does not include assuming
responsibility and power

promoting SNS site. Once enrolled, they received multiple updates

to their own SNS page, and could post comments on the health
promotion page in reaction to any update (Bull et al., 2011;
Mankoff et al., 2007). Authors point out that one needs to
intensely interact with the target group (Bull et al., 2011; Gold
et al., 2011), e.g. by responding to comments, posing questions or
launching polls. However, there is so far no evidence if these
interventions have an effect on health behavior or health outcome.

remains unclear. Health promotion also faces many challenges

with regard to brand-authored social media marketing, because
regulatory strategies are hard to implement in an environment
such as SNS, which are essentially unregulated and possibly
uncontrollable (McCreanor et al., 2013; Nicholls, 2012).

3.2. Changing the physical environment, organizational and

social structure and/or policies

About this characteristic: Building partnerships with and obtaining commitment of direct stakeholders of a setting is important in
order to negotiate entry into this setting, facilitate organizational
changes, and transfer ownership (Gillies, 1998; Kreuter et al.,
2000; Parcel et al., 2000; Poland et al., 2009). In terms of Healthy
Schools, for example, these stakeholders are students, teachers,
school nurses, caterers, and parents (Dooris, 2004; Parcel et al.,
2000). Dooris (2004) also points out that whilst different settings
are in some senses discrete, they are also interconnected, and
one setting may be located within the context of another. Therefore, it is important to link setting-based projects to initiatives
within other settings as well as with the wider community l e.g.
by implementing networks between workplaces, health and social
care, and cities.
Can this be transferred to SNS? Research on how partnerships for
health promotion could be established in SNS is limited. This is
certainly due to the fact that it is more difcult to make out certain
groups of stakeholders, as compared to schools or communities.
Beside the SNS users and their friends, the only other stakeholders that can be identied within social media are public or
private organizations that have their own Facebook or MySpace

About this characteristic: The settings approach aims at changing those environmental, structural and political conditions of
the setting that inuence health and/or make it difcult for people
to behave in a healthy way (Dooris, 2004; King, 1998; Whitelaw
et al., 2001). The importance of creating supportive environments
for health builds on the Sundsvall Statement issued by the WHO in
1991 (Haglund et al., 1996).
Can this be transferred to SNS? There are hardly any reports
about how interventions can succeed in changing the environment, the technical and organizational features of SNS. We found
only one study whose aim could be categorized as changing the
environment of SNS0 . In this study by Moreno et al. (2009), young
adults with a publicly available MySpace prole were asked to a)
eliminate all references to risky sexual behavior or substance
abuse, and b) change prole security to private. The intervention
could motivate a proportion of users to remove risky sex references, and to change their prole security. Whether these changes
eventually resulted in a better health of the user0 s network

3.3. Building partnerships within the setting, developing links

to other settings or to the wider community

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presence. A study by Apatu, for example, found a multitude of

driving safety groups on Facebook and advised health promoters
to pair with those groups in order to broaden the reach of driving
safety interventions (Apatu et al., 2013). One should also consider
linking SNS to those ofine settings whose members communicate frequently with each other on SNS. This is all the more
reasonable as most of the health risk behaviors that SNS users may
refer to in their communication have taken place in the ofine
world (see above). Dooris0 observation that health issues do not
respect the boundaries of settings0 (2004) very well applies in the
case of SNS. For example, if a large number of students in a school
are connected within SNS, then SNS can be considered as a setting
within the context of the school setting, and health promotion
initiatives could address both social contexts, or address people
that live their lives within both settings.
Another potential partner for health promotion are those actors
who are responsible for the technical features of SNS and their
dynamics, i.e. the (multinational) corporations that own and
operate the websites. However, they usually remain in the background but in theory, building a partnership with them would be
an innovative way for health promotion on SNS.
3.4. Seeking participation of setting members and employing
strategies to empower them
About this characteristic: The principles of participation and
empowerment have been a hallmark of the WHO vision of health
promotion (World Health Organization, 1986). Through participation, people assume greater responsibility for health problems,
and act to implement solutions by forming groups and organizations (Bracht and Tsouros, 1990; Zakus and Lysack, 1998). Thereby,
this concept is linking with the concept of empowerment.
Empowerment is dened as gaining understanding and control
over personal, social, and political forces in order to improve one0 s
life situations (Wallerstein, 2006; Zimmerman, 1995).
Can this be transferred to SNS? Web 2.0 offers a potential for
public health practitioners to engage with citizens in a multidirectional way. SNS allow people to be content contributors and
may therefore be an arena for active participation (Centre for
Health Promotion and Women0 s and Children0 s Health Network,
2012; Thackeray et al., 2012). However, it seems that the level of
participation achieved by current health promotion projects on
SNS is limited to the users0 feedback to health messages, or to
consulting with users on health messages (Bull et al., 2011; Gold
et al., 2012). Two-way communicative interaction alone does not
necessarily correspond to the concept of participation as described
above, which includes assuming responsibility and initiating
actions by users. According to the famous ladder of participation
put forward by Arnstein in the 1960s (Arnstein, 1969), consultation
alone would be categorized as tokenistic participation.
On the other hand, the recent political revolutions in the
Middle East brought attention to the use of SNS for the mobilization of social movement (Laverack, 2013; Schwarz, 2011). The use
of contemporary small media, including SNS such as Facebook or
Twitter, mobile telephony, and e-mails, promoted the bonding of
people in repressive regimes and contributed to initiating collective actions, which lead to the wave of political unrest in the
Middle Eastern region known as Arab Spring(Sreberny, 2012).
Indeed, SNS have a potential to link people with common interests
or concerns and thus to mobilize people to promote a particular
(ofine) cause together with others (Jones, 2011; Schwarz, 2011).
In general, the Internet can facilitate online social movement
activism and protest, by tactics such as online petitioning, boycotting, and e-mailing campaigns (Schwarz, 2011), as was shown by
protests against Facebook0 s ban of breastfeeding photography
(Khan, 2008). SNS can also be used to organize ofine actions on

health or related issues (Laverack, 2013), thus fostering participation and empowerment of users with regard to the ofine
setting. Examples include user-driven SNS groups on issues such
as driving safety or climate change (Apatu et al., 2013; Mankoff
et al., 2007). In addition, some websites like GoFundMe and You
Caring help users connect to social media like Facebook to solicit
donations in the area of medical expenses. This online version of
crowdfunding has been successful in raising money for healthrelated campaigns, although mostly for individual medical bills
(Sisler, 2012). These SNS activities are bottom-up movements
which have been started off by affected or concerned users. It is
unclear yet whether and how public health professionals can
initiate, as a health promotion strategy, comparable forms of
active participation, empowerment and community action around
a specic health issue.

4. Discussion
Can SNS such as Facebook be viewed as a novel setting for
health promotion in its socio-ecological sense? We found that
despite the increasing interest in the potential of Web 2.0 technology
for health promotion, research and evaluation on the use of SNS for
health promotion is limited. We summarize our ndings by putting
together the arguments in favor of and against such a view.

4.1. SNS as a setting for health promotion: pro

Many of our working and living conditions have shifted from
geographically bounded locations to the cyberspace within the last
years, e.g. working from home, distance learning, or spending
leisure time in online communities. Therefore, 30 years after the
Ottawa Charter, the terms of place and environment may need
to be re-dened with regard to the healthy settings concept; social
interaction and a community of interests may gain more importance when dening a setting for health promotion. Especially
among adolescents, websites such as Facebook are favorite communicative platforms for social interaction and the pursuit of
certain personal tasks, e.g. sharing information and getting to
know people. The individuals0 activities on SNS are shaped by a
structure of technical services and applications, which allow
posting personal information and pictures, giving feedback and
publicly commenting on posts of other users. These structural
features can be regarded to form the environment of the setting
of SNS. This environment can affect the health of users, e.g. if users
of a SNS are regularly exposed to their friends0 references to risky
or self-destructive behavior, especially if it is portrayed in an
attractive way, if they share links to SNS sites or online ads from
dangerous consumption industries, or if it is a platform for cyberbullying. Health promotion interventions can use SNS, e.g. by
setting up a Facebook site on a health-related issue and enrolling
participants to become fans of this site, and can thereby not only
distribute health messages, but also initiate an exchange of ideas
among SNS users. This can foster active participation and critical
consciousness and develop skills of users. Taking the experiences
of online activism as well as organizing ofine protests, e.g. in the
Arab world, SNS may even have the potential for health promoters
to empower users so that they get mobilized to advocate for a
common health concern in joined action. Therefore, interventions
on SNS may address skills development, participation and empowerment among participants essential elements of settings
based health promotion. From this point of view, SNS seem to be
an attractive new setting for health promoters.

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4.2. SNS as a setting for health promotion: contra

The millions of SNS users worldwide do not, even on a regional
or socio-demographical level, form a collective entity that might
represent a community of interests or a setting with a closed
membership. Therefore, health promotion interventions can only
reach individuals who might (or might not) transfer health
information to their respective individual network contacts, but
it cannot reach x groups tied together by shared interests or
spatial boundaries. In addition, the only activity that people
pursue on SNS is written communication. In consequence, if we
took the settings approach seriously, the only personal behaviors
that health promotion interventions could address in SNS were
those practiced in the very setting, i.e. wording, communication
styles as well as relationships, with the indirect aim of enhancing
empowerment, self-esteem, and wellbeing (Valkenburg et al.,
2006). Most published SNS interventions, however, focus on the
underlying health-related behaviors that SNS users communicate
about e.g. drinking which are practiced in the ofine world.
Using online social media in order to address ofine health
behavior is probably only just consequential, because the wellknown health promotion strategies that are meant to make the
setting itself a healthier place e.g. building partnerships, changing the political and environmental structures can hardly be
applied to SNS. Besides the individual users, there is hardly any
other stakeholder or decision-maker that can be allied with for
capacity building if one is not to approach the companies
running the SNS. Therefore, within the realm of SNS, health
promoters are restricted to mere communication to end-users. It
remains to be shown whether this communication can succeed in
is getting users involved in active participation for health issues, or
successfully empowers users so they can take action in favor of
their health online or ofine.

5. Conclusion
Especially in terms of adolescents and young adults, SNS are
too important a communicative social venue to be completely
neglected by health promoters. The opportunities of Web 2.0 technologies hold great promise, but also raise many questions for
traditional health promotion. Social networking methods have
begun to appear on many health promotion sites run by public
health organizations, and SNS have proven to be ideal for encouraging interpersonal interaction and for providing information about
how to become civically and politically involved. However, there is
still a striking lack of published health promotion interventions
initiated by public health organizations that deliberately and
comprehensively leverage SNS to achieve health promotion goals,
and therefore a paucity of evaluation and research. Thus we have
little points of reference about whether or not SNS can successfully
be used for health promotion projects that go beyond mere twoway, interactive health education. In the future, more interventions are needed that fulll the criteria given by Korda & Itani:
basing on a theoretical model, measuring change, and scaling for
broader impact (2013), in order to generate more solid evidence
on how SNS may be used for a Healthy Settings approach. Based
on the current literature, we have shown that one should be
cautious in uncritically attributing the term of a novel setting to
SNS.
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