Within the past 30 years or so, the focus in global health promotion has shifted from a traditional biomedical–epidemiological illness-centered perspective towards wider recognition of the social and environmental determinants of health inherent in settings [7]. This way of thinking highlights the definition and understanding of ‘environmental’ factors that influence the health of individuals or communities directly or indirectly. Previously, people’s lifestyle decisions were seen as depending on individual choices and decision-making that were freely made without any influence of the context or living conditions. This meant that individuals’ health, or in fact ill health, was center-stage. Health promotion was equal to individual-centered disease prevention through a focus on individual health behaviors, including physical activity behavior, which was mediated through individual factors, such as knowledge of the benefits of physical activity or motivation etc. Today it is recognized that people’s health, along with individual-based factors, is mediated through settings-based factors. This, in turn, has widened the determinants of health to emphasize contexts of living, as is well demonstrated in one of the fairly recent definitions of health promotion :

Health promotion aims to empower people to control their own health by gaining control over the underlying factors that influence health. The main determinants of health are people’s cultural, social, economic and environmental living conditions, and the social and personal behaviours that are strongly influenced by those conditions [8].

In addition to these pragmatic aspects of the focus on settings, a key factor behind the increased theoretical and strategic interest in the settings approach has been the ecological perspective of health promotion, which demands that individuals not be treated in isolation from the larger social units in which they live, work, and play. These essentially sociological and anthropological perspectives expanded health promotion beyond the largely psychological perspective or dominance of its forerunners in health education, social marketing, and behavior modification.

Different settings are also important in health promotion because of the way that they shape contextual boundaries. Context, in turn, is central to ecological approaches in health promotion and public health , where people’s health-related opportunities and behaviors can be supported through organizational policies and environmental changes [9–11]. Settings also represent a fundamental aspect of practice, recognizing the particular needs and living (working, schooling, recreational) circumstances of the target groups of interventions [12]. Settings define the audiences of interventions (individually, collectively and organizationally), and the channels for predisposing, enabling, and reinforcing factors of health-related behaviors. The incentives required to assure the cooperation of the setting will be partly determined by the position of health promotion relative to its core-business [13]. The setting itself, in most cases, is also framed as a target of intervention, with community-wide programs usually involving multiple and varied settings [14]. Most health promotion activity is bound in time and space within settings that provide the social structure and context, i.e., setting-specific features for planning, implementing, and evaluating health promotion.

The settings approach, evidently, has become one of the fundamental international foundations of health promotion. The first two initiatives using the approach were focused on cities and schools. Thereafter, workplaces, universities, hospitals, and prisons have been targeted. Many of these setting-based initiatives have spread across countries, continents or even worldwide [15]. Lately, there has been a drive to broaden the reach of the settings approach into non-traditional, non-institutional settings [8, 16], with projects being established, for example, in beauty salons, farms, sports clubs and/or organizations, and sports arena/stadia.

The diminished focus on individuals in health promotion does not mean that individuals are ignored. Indeed, individuals’ behaviors and decision-making processes remain principal factors determining their health, but the emphasis is clearly placed on the settings and ecological factors that shape, limit, or enhance those behaviors and decisions. One often forgotten factor in settings-based work is the reciprocal determinism between a setting and the behavior of the people within it—the setting can shape and constrain health-related behaviors (and by changing the environment it is possible to modify these behaviors or actions), but at the same time behaviors or actions of people also influence the setting [17, 18]. Ideally, an intervention will empower and equip people with the health literacy and knowledge to adjust their behavior to changing environments or adjust the environment to their changing needs [19].

To execute health promotion in settings is not the same as to plan and develop health-promoting settings or settings-based practice [20]. The key question in settings-based health promotion is how strongly the setting in question is involved in its development. Settings are typically divided into five models (passive, active, vehicle, organic, and comprehensive) [21] in which, to achieve the best possible results, the experts’ role is to act as agents of transformational change, stimulating the people within the setting to begin changing it. The setting can be, and perhaps at early stage needs to be, used as a strategic route to the key stakeholders. Still, the usage of the setting as a passive channel of communication should only be a first step in undertaking settings-based health promotion and not regarded as an end in itself.

In the first and most traditional model (the passive model) the setting, unsurprisingly, has a fairly passive position—‘only’ offering a channel for outside experts to reach the people in that setting. Sport settings offer existing channels and social environments for developing sporting adolescents’ health knowledge and skills, In this model, health promotion is usually done with a focus on a specific health or social problem and implemented by an outside expert, without a clear relationship to the core-business of the particular sport setting (e.g., athlete development in sports clubs), separately from sport activities and without input from stakeholders in the setting (except in allowing the work to happen).