Status of the Health Promoting University (HPU) globally and its relevance for emerging African HPUs: an integrative review and bibliometric analysis

Abstract

Background:

The Health Promoting Universities (HPU) concept is undertheorized, with no African university belonging to the International Network of Health Promoting Universities (IHPU).

Aim:

The study aimed to investigate the status of the HPU concept globally to inform emerging HPUs, more specifically in Africa, regarding its implementation.

Methods:

An integrative literature review of studies conducted between 1 January 2013 and 5 November 2023 was conducted from online databases (PubMed, Scopus, Web of Science, Lilacs, CINAHL and Medline). A VOS bibliometric analysis viewer was used to extract and analyze further relevant information that could have been missed in the review.

Results:

From 1128 records, 22 (N = 22) articles including two reports met the inclusion criteria. The main findings were that: (1) the HPU network is growing as a global network though undertheorized and less reported on, (2) the implementation of the HPU depends on a plethora of underpinning philosophies such as salutogenic and whole systems approach, and diverse programs and initiatives, 3) the terms HPU and healthy universities are often used interchangeably but the whole systems approach appears to be consistent in many HPU interventions. However, five contextual challenges that emanated from this review were discussed, including the definition of the HPU concept, theories for the HPU concept, measurement of the HPU concept, coordination and methods for measuring the HPU concept status. These challenges present obstacles to measuring the status of the HPU concept beyond the number of affiliated universities and HPU initiatives.

Conclusion:

Despite the challenges, the HPU concept is gaining momentum globally, as evidenced by the growing list of universities (HPU network) involved and the proliferation of interventions/initiatives targeting university students.

Introduction

The Health Promoting University (HPU) concept, influenced by the Ottawa Charter (1), is central to promoting health amongst university students globally, as expounded by various authors (2,3). The evolution of the HPU concept can be traced back to 1996, leading to the concept’s launch in Europe (4). It was later promoted through various conferences, leading to charters such as the Edmonton Charter (5) and the Okanagan Charter (6). The conference leading to the launch of the Okanagan Charter (2015) was attended by 375 participants from 30 countries (7), signifying the growing number of HPU networks and the popularity of the HPU concept. The terms HPU concept and healthy universities are used inter-changeably (7,22); thus, the term HPU concept is used for this study.

The HPU concept comes against the backdrop of poor health habits reported by several scholars globally and the devastating impact of non-comm-unicable diseases (NCDs). According to the World Health Organization (WHO) (8), almost 500 million people will develop heart disease, obesity, diabetes or other NCDs attributable to physical inactivi-ty between 2020 and 2030. To intervene will cost US$27 bn annually if governments take urgent acti-on to encourage more physical activity among their populations. Physical activity is one of the key cri-tical areas of the HPU concept (8). The HPU concept is mainly premised on the whole systems approach, hence the proliferation of terms referring to the HPU concept (9).

Many national and international networks related to the HPU concept have been formed mainly on four continents (2,9). The African continent has been reported to be lagging in the implementation of the concept and also the formation or affiliation to an international HPU network (9,10). Only one South African university belongs to a network similar to an HPU network − the International University Sports Federation (FISU). Furthermore, there is a lack of theoretical frameworks to base its full implementation on (2,9). There is also a need to identify the key indicators for an HPU. Theoretical frameworks used in other developed countries, specifically Europe, need to be contextualized to the African continent and regions, fully considering current university settings and frameworks (10). However, to fully implement the HPU concept in other continents like Africa, an understanding of the current HPU status is inevitable. The study’s objective was to investigate the status of the HPU concept globally to inform emerging HPUs, more specifically in Africa, regarding its implementation.

Materials and methods

To achieve the proposed objective, we opted for an integrative review – a method that provides a synthesis of knowledge. Studies conducted between 1 January 2013 and 5 November 2023 were included in the integrative review. The rationale of the time frame (2013–2023) was to review the most recent articles regarding the implementation of the HPU/healthy universities frameworks. All relevant articles published in all languages including qualitative, quantitative and mixed methods focusing on the HPU concepts were included. Articles were constrained to the HPU con-cept/healthy universities approach to delimit the study and gain more insight into the implementation of the concept globally. Status was interpreted with regard to the main objectives of the HPU concept. A bibliometric analysis using VOSviewer software was also conducted for further insight into the HPU network and comm-on terms used in the HPU discourse (https://www.vosviewer.com/).

Search strategy

The authors systematically searched documentary evidence from electronic databases including PubMed, Medline, CINAHL, Lilacs, Web of Science and Scopus. The following search terms and filters were used: ‘health promoting universities’ OR ‘healthy univer-sities’ OR ‘HPU’ AND (full text: AND db:(‘ME-DLINE’ OR ‘LILACS’ OR ‘CINAHL’) AND mj:(‘Health Education’ OR ‘Universities’) AND type_of_study:(‘qualitative_research’ OR ‘observational_studies’ OR ‘evaluation_studies’ OR ‘guideline’ OR ‘systematic_reviews’ OR ‘sysrev_observational_studies’ OR ‘overview’ OR ‘policy_brief’ OR ‘str-uctured_summary_of_systematic_review’) AND (ye-ar_cluster:[2013 TO 2023]). In the PubMed database, the search terms were: ‘Health Promoting University Students’ or ‘HPU’, ‘Health Promoting Universities’ or ‘whole universities’. Furthermore, one similar article that closely resembled the search terms was used to retrieve the most relevant articles for the search question. All searches were conducted directly without using an intermediate interface such as Ovid. The authors read the abstracts and the main findings to screen the articles suitable for this study according to the eligibility criteria cited below.

Eligibility criteria and selection of studies

Articles focusing on the HPU concept holistically were considered to address the study’s objective. For this study, a holistic focus would imply the use of an underpinning theory, concept or framework influenced by the HPU concept, for example, whole systems approach, healthy universities, and campus interventions, and also conformity to the main item areas of the HPU concept according to a review by Tafireyi and Grace (9). Studies also needed to have been published between 2013 and 2023 to get the most recent and relevant studies regarding the implementation of the HPU concept. Reviews and studies of a report, evaluative, exploratory and descriptive nature were mostly considered. Studies that focused on only one item area or action area of the HPU concept were not considered unless the focus was on a broader concept such as physical activity, as well as those that did not attempt to review, describe or evaluate the implementation of the HPU concept in global universities.

The titles and summaries of the selected studies for inclusion in the full-text review were autonomously evaluated by two reviewers. Only those full-text studies that both authors agreed with and met the inclusion criteria were selected for full-text review eligibility. Mutual unanimity between the two re-viewers ensured differences were minimized. To find eligible supplementary studies, the two reviewers searched the reference lists and citations of included studies.

Quality assessment

The authors used the objectives of the HPU (3) to check the compliance of the articles to at least three action areas and underpinning philosophies such as the whole systems approach.

Data extraction and analysis

Relevant information such as year of publication, study method, study focus, results and conclusions (main observations) were extracted from the included studies. The information was summarized and recorded in tables. Analysis was based on the status of the HPU (the aim of the study), which could also be implied if not directly evident from the findings. The thematic method was used to come up with the main themes in the results section.

Results

The searched databases identified 1128 articles, of which 1018 were removed due to ineligibility and 108 were screened. Of the 108 articles, 88 were removed and did not fully meet the inclusion criteria. After checking the eligibility of full-text articles, applying exclusion criteria, and screening, 20 studies (n = 20) plus two reports (n = 2) met the inclusion criteria (2,7,9,11 –29), as portrayed in Figure 1. Mendeley Desktop reference was used to identify duplication and apply data management. For the Bibliometric analysis, the same articles were used, plus seven others that did not fully meet the inclusion criteria (Figure 1) but addressed at least one item of the HPU. One report from the initially selected 22 articles did not meet the supportive version of Bibliometric analysis; hence it was removed. The-refore, 28 articles (21+7) were selected for the Bibliometric analysis.

Figure 1.

PRISMA flow diagram showing the selection of studies.

Study characteristics

The selected studies and reports (N = 22) com-prised six theoretical/qualitative research studies (2,13,16,17,26,27), four mixed methods studies (7,18,20,23), two quantitative/questionnaires (19,24), two reports (11,29), one network analysis (12) and seven reviews (9,14,15,21,22,25,28). The main findings are presented in Table 1.

Table 1.

Characteristics of articles.

Title of the article	Type of study/methods	Focus/objectives of the study	Main observations	HPU status deductions
Informe SESPAS 2018 (The university as a community: health-promoting universities. SESPAS Report 2018) (11).	A report study.	Focused on the HPU concept.	The creation of HPU networks in 2003 in Latin America took the form of the Ibero-American Network of Health Promoting Universities in 2007, and was within the framework of the III Congress of Health Promoting Universities held in Ciudad Juárez, Mexico. In Spain, the Spanish Network of Healthy Universities was created in 2008 with the aim to reinforce the role of universities as environments promoting the health and well-being of both their students and their staff and society, leading and supporting processes of social change.	Many HPU networks have been created in four continents, signifying the growth of the HPU movement.
Promoting students’ health at university: key stakeholders, cooperation, and network development. Front Public Health (12).	A network analysis study.	To visualize and describe the positions and characteristics of the network actors and examine organizational relationships to determine the characteristics of the complete network.	The university sports center is considered the most important actor in the context of students’ health. Presidium and Institute of Sport and Sports Science play an integral role in terms of network functionality.	The university sports center takes charge of HPU initiatives.
The application of salutogenesis in universities. In: The Handbook of Salutogenesis (13).	Theoretical research (book chapter).	How health can be created, maintained and supported in university settings. It first explores the higher education context and introduces key concepts underpinning healthy universities and applying a settings approach within this sector.	Healthy Universities has explicitly emphasized whole system approaches and drawn on socioecological theory and systems thinking, emphasizing the importance of creating environments and contexts that support and maintain health, well-being and human flourishing. Although informed by salutogenic orientation, Healthy Universities implementation and research have tended not to be framed explicitly in terms of salutogenic constructs. Higher education has witnessed a growing focus on well-being, resilience and coping – perspectives that are not the same as, but clearly relate to, salutogenesis. Universities are complex systems and in guiding future developments, it will be important that salutogenic thinking informs research, policy and practice at multiple levels.	Healthy universities are based on the whole system approach and are mainly influenced by salutogenic orientation.
Health promotion programs in higher education: an integrative review of the literature (14).	An integrative review of the literature (17 articles included).	To characterize the interventions of health promotion programs implemented in HPUs; to analyze the results of the interventions of health promotion programs.	The health intervention promotion programs aimed at increasing the welfare of students, with an emphasis on physical activity, sexual health and improving the environment of health support within the university community. Health promotion strategies in a university context do not always result from converging educational, political, legislative or organizational actions.	HPU strategies are not always a result of converging educational, political, legislative or organizational actions. Other interventions are possible for the promotion of health among university students.
Health literacy among university students: a systematic review of cross-sectional studies. Front Public Health (15).	Systematic review of cross-sectional studies (21 research studies).	To provide an overview of cross-sectional studies examining university students’ health literacy and identify possible determinants related to health literacy.	The majority of studies report health literacy scores among university students that are lower compared with reference samples. Students’ health literacy is influenced by different variables (age, gender, number of semesters, course of studies/curriculum, parental education, and socioeconomic background).	Most students not health literate due to many factors. This might signify slow adoption of the HPU/healthy universities approach influenced by whole settings.
The physical activity and health promotion activities of global university students: a review of reviews (9).	A review of reviews (studies).	To review global universities’ physical activity and health promotion activities to inform the PA and HP guidelines for Eswatini University students in the Sub-Saharan region.	Some global universities follow the HPU concepts influenced by the Ottawa Charter (1986). The main item areas of health promotion are smoking control/alcohol and drug abuse, mental health, sexual health, physical activities, and healthy eating habits The main PA activities were pedometer activity tracking, and measurement of PA using validated questionnaires, sports, games, among other intervention activities.	Main item areas of the HPU are: smoking control/alcohol and drug abuse, mental health, sexual health, physical activities, healthy eating habits. The main PA activities were pedometer activity tracking, measurement of PA using validated questionnaires and sports participation.
The UK healthy universities self-review tool: whole system impact (7).	Online questionnaires and focus groups.	This paper reports on research exploring the use and impact of the UK Healthy Universities Network’s self-review tool, specifically examining whether this has supported universities to understand and embed a whole system approach.	The self-review tool was extremely valuable and, when engaged fully, offered significant benefits to universities seeking to improve the health and well-being of their communities. These benefits were felt by institutions at different stages in the journey and spanned outcome and process dimensions.	Evaluation critical for the HPU implementation, e.g. UK self-review tool.
Comprensión e implementación de la promoción de la salud en instituciones de educación superior en Colombia [The understanding and implementation of health promotion at higher education institutions in Colombia]. Rev Salud Publica (16).	A qualitative study with an ethnographic approach was carried out at 11 institutions selected in five cities.	To characterize the implementation and understanding of health promotion at higher education institutions in Colombia.	These institutions have implemented policies and programs and undertaken actions like education, reorientation of health services, participation and intervention in the environment, as well as research and activities with family and community outreach. Different scopes related to the development of health promotion were found, i.e. there was a preventive approach and an inter-sectorial outlook with a broad extent.	Implementation of diverse policies and programs towards HPU.
How does the campus environment influence everyday physical activity? A photovoice study among students of two German universities. Front Public Health (17).	A photovoice method to thoroughly understand students’ daily life on campus. Forty-six university students in two German cities (university 1: n = 22, university 2: n = 24).		Both universities do not exploit their potential to foster daily physical activity on campus, according to the photos and discussions of the participating students.The vast green spaces offer no cues for movement: easily accessible equipment for sports (fixed or mobile) is lacking, walkways are partially hidden, and the facilities discourage cycling to and on campus.Social norms induce participants to keep sitting during lectures and learning time.Indoor hallways and foyers could be put to better use concerning physical activity. The Photovoice project raised the participants’ awareness of how the context influences their movement behavior. It helped them develop solutions to make physical activity easier for students at their respective universities.	University campuses not fully exploiting the HPU through the whole settings approach. The photovoice method is novel for exploring the whole settings approach discourse.
Healthy universities: an example of a whole-system health-promoting setting (2).	Documentary analysis, observation field notes and semi-structured interviews with staff and students.	This study explores how the concept of a healthy university is operationalized in two case study universities.	The concept of healthy universities has been slow to be adopted compared with healthy schoolsLack of theorization for healthy universitiesPaucity of evidenceDifficulties in capturing the added value of the whole systems approach	Healthy universities slowly adopted.
Conceptualizing the ‘whole university’ approach: an international qualitative study (18).	A multi-method qualitative approach was used.	The study that explored vice-chancellors’ and network members’ understanding of and commitment to HPUs, examined perspectives on leadership and investigated the Okanagan Charter’s potential to catalyze whole university leadership and change.	The HPU is confirmed as a truly global movement in four continents signifying the growth of the network.Even with the Okanagan Charter inspiring individuals and universities, there are still major challenges in translating the rhetoric of whole system approaches into meaningful action within large, complex and culturally diverse organizations.	HPU has existence in four continents, mostly influenced by the Okanagan Charter.Challenges of putting the whole systems approach into practice.
Healthy Universities: a guiding framework for universities to examine the distinctive health needs of its own student population (19).	Quantitative data were gathered from 3683 students studying at a UK urban university. A 60-question online student questionnaire focusing on seven key topic areas was used to gather data and simple descriptive statistics are used to present key findings.	This study examined the student health behaviors of one university so that future initiatives can be tailored to its own student population.	The study has identified a need for considering alternative ways of engaging students with appropriate health services throughout the academic year.A focus on university initiatives around healthy eating options, how to cook healthy food and the importance of keeping hydrated is highlighted as a common need.Risky behavior involving alcohol, drug and substance use and sexual activity suggests a strong argument for not separating university sexual health and alcohol interventions.	A common need for the HPU university is initiatives around healthy eating options.Consideration of diverse interconnected activities is critical.
Student perceptions of a healthy university (20).	Student surveys and focus groups were used to collect data across 11 universities in England, Scotland and Wales. A priori themes were used to develop our own model for a healthy university, and for the thematic coding phase of analysis.	This paper presents findings from consultative research undertaken with students from universities in England, Scotland and Wales, which explored what they believe represents a healthy university.	A healthy university would promote student health and well-being in every aspect of its business from its facilities and environment through its curriculum.Access to reasonably priced healthy food and exercise facilities were key features of a healthy university for students in this study.The self-review tool has provided a crucial start for universities undertaking the journey towards becoming a healthy university.In looking to the future both universities and the UK Healthy Universities Network will now need to look at what students want from their whole university experience, and consider how the self-review tool can help universities embrace a more explicit conceptual framework.	Whole systems approach important for the HPU concept.Self-review tool critical towards the healthy universities.
Implementing the Health Promoting University approach in culturally different contexts: a systematic review (21).	Systematic review: selected articles were content analyzed paying attention to (a) the definition of a HPU; (b) priority areas of action; (c) items of work; (d) coordination of the project; (e) evaluation; and (f) adaptation to the cultural context.	This systematic review aims to describe how universities have implemented the HPU concept in different cultural contexts.	The programs described in the selected studies are mostly based on the guidelines of the Edmonton Charter.They incorporated the main areas of action and items of work proposed by the HPU framework.The implementation of healthy policies and incorporation of health promotion in the curriculum are remaining challenges.Strategies to facilitate adaptation to context include stakeholder participation in planning and implementation, adaptation of educational material and analysis of needs.The review suggests that most of the universities work towards similar goals, relying on the HPU framework, yet that the way in which initiatives are implemented depends on the context.	Universities are incorporating the HPU framework based on the Edmonton Charter.
Theorizing healthy settings: a critical discussion with reference to Healthy Universities (22).	A scoping literature review was undertaken between 2010 and 2013, identifying 26 papers that met inclusion criteria.	To identify what theories and conceptual models have been used in relation to the implementation and evaluation of Healthy Universities.	Seven theoretical perspectives or conceptual frameworks were identified: the Ottawa Charter; a socio-ecological approach (which implicitly drew on sociological theories concerning structure and agency); salutogenesis; systems thinking; whole system change; organizational development; and a framework proposed by Dooris.	Theoretical frameworks influence the HPU approach therefore intervention programs must be influenced by them.
Creating healthier graduates, campuses and communities: Why Australia needs to invest in health promoting universities (23).	Mixed methods.	Settings-based health promotion project.	Leadership is required from Australian universities to invest in health promotion. This is the time for higher education in Australia to consider its role in shaping the health of its local and global communities.	Higher education leadership lacking for the effective implementation of the HPU framework or healthy universities.
How do universities implement the Health Promoting University concept? (24).	An online questionnaire was used to assess the action areas and items of work addressed by the universities and to determine their adherence to the components of the HPU framework: use of the whole systems approach; multiservice collaboration; recognition by the university authorities; funding availability; membership of a HPU network and evaluation of the initiative.	This study explored the way in which 54 universities from 25 countries across the world implemented the HPU framework.	Most universities addressed: the use of the whole systems approach; multiservice collaboration; recognition by the university authorities; funding availability; membership of an HPU network and evaluation of the initiative.	Most universities use major areas of the HPU framework.
The whole and inclusive university: a critical review of health promoting universities from Aotearoa New Zealand (25).	A critical review.	This paper provides a critical review of the existing HPU approaches which is informed by health promotion values.	The authors introduce the New Zealand university landscape, in which there are eight Western universities and three whare wānanga (Māori universities), and, drawing on a survey of their Charters and other official statements, offer a moemoeā (vision or dream) of an HPU that addresses structural discrimination, is based on holistic conceptions of health, and is centered on indigenous worldviews and concerns.	Initiatives based on holistic concepts of health and indigenous worldviews.
Developing a health promoting university in Trinity College Dublin – overview and outline process evaluation (26).	Qualitative paper.	Using and expanding on the HPU platform within HEIs, this article provides a description of Healthy Trinity, which is an initiative underway in Trinity College Dublin, the University of Dublin.	Healthy Trinity is contextualized in background literature including international and national policy and practice.	Initiatives of the HPU have been developed, including the Healthy Trinity.
Factors influencing the implementation of the Health Promoting University initiative: experiences of Ibero-American universities (27).	Semi-structured interviews were held with 17 representatives of universities in Ibero-America that had implemented an HPU initiative.	This study aimed to identify the factors influencing the implementation of HPU initiatives in Ibero-American universities.	The main factors influencing the implementation of an HPU initiative were political support by the university authorities, coordination structure, funding, collaboration inside and outside the university and participation of the university community. Among them, political support by the university authorities was considered the most important, although some initiatives succeeded without it and managed to obtain support during the implementation process.	Political support by the university authorities is most important for the effective implementation of the HPU initiative.
[Analysis of the promoting actions of physical activity developed by Valencian public universities] (28).	Review and qualitative study.	The purpose of this study was to analyze and review the activities developed by the RVUPS on the promotion of Physical Activities in the university context.	Currently, Valencian universities do not cover all the needs to achieve an adequate well-being state. In response, some universities from RVUPS offer individualized activities to prevent and treat some of the chronic pathologies that currently have the highest incidence in the population. In addition, new services are being implemented which integrate all health professionals in order to achieve a more comprehensive service to their population. The qualitative study revealed that interviewees also perceive such needs and, therefore, support these initiatives, considering that a physical activity and nutrition service would be an interesting option for implementation in universities.	Universities not fully implementing the whole settings approach, which is an important factor of the HPU/healthy universities frameworks.
The FISU Healthy Campus Best Practices. 2021–2022 (29).	Best practices e-book. Report on 130 universities in 39 countries.	Program based on: healthy campus management, physical activity and sport, nutrition, and disease prevention, mental and social health, risk behavior, environmental sustainability and social responsibility.	Universities design programs that address one of the FISU focal areas, implement and evaluate them.	More than 130 universities from 39 countries registered for the Healthy Campus program since 2020 and have since implemented programs that have been recorded in the FISU latest publication.

Source: Own study.

HPU: Health Promoting University; PA: Physical Activity; HP: Health Promotion; HEI: Higher Education Institution; RVUPS: Valencian Network of Healthy Public Universities; FISU: International University Sports Federation

Synthesis

Context/semantics of the HPU

What is clear from the studies reviewed is that the terms HPU and healthy universities/whole systems approach are used interchangeably (2,7,9,11–29), and the term HPU does not specifically refer to the HPU movement. Activities being implemented by universities are not explicitly influenced by the HPU (2,7,9,11 –27).

Growth and coordination of the HPUs

The number of HPU network universities continues to expand in Europe and Latin America, and not much has been reported in continents like Africa (9,11,13,24). The HPU network exists mainly on four continents and is described as a truly global movement (11). However, some HPUs do not operate under the political leadership and coordination of university authorities or networks though it is highly encouraged to gain the support (14,23,26). The FISU Healthy Campus program is not part of the IHPU but is fast growing, with more than 130 universities from 39 countries and only three from Africa registered so far (29).

Reporting on the HPU

Some studies included in this study agree that there is not much reporting regarding the success of the HPU movement, even though there is a growing focus on promoting health and well-being among universities globally (9,14). Many studies focus on different institutional interventions with the HPU/healthy universities approaches as underpinning health promotion frameworks (7,9,14 –19,29). Ho-wever, the FISU Healthy Campus program is well documented and showcases how registered uni-versities have designed, implemented and evaluated the program they have offered according to the focus areas of the FISU Healthy Campus label (29).

Theories and charters influencing the HPU concept

It was also reported that although the underpinning philosophy of some HPU initiatives is mainly sal-utogenic, some universities’ HPU programs are not entirely influenced by it (13). The socioecological theory is also applied by other universities for their HPU programs. These philosophical underpinnings of the HPU concept, including Ottawa, Edmonton and Okanagan charters, were seen to be influencing various HPU initiatives in many global universities (13,18,21,22).

Intervention programs/HPU initiatives

Furthermore, intervention programs focusing on promoting health and well-being are popular with many universities. These interventions include: phy-sical activities, sexual health and mental health programs (9,29). However, some studies reported low health literacy among university students (15) and slow adoption of the healthy universities approach (2,15). The authors discovered that students’ health literacy is influenced by different variables (age, ge-nder, number of semesters, course of studies/cur-riculum, parental education, and socioeconomic ba-ckground); hence, health literacy activities should target all students (15). It was reported that self-re-view tools were valuable for health and well-being promotion in United Kingdom universities (7). The tools are complemented by policies (13) on health promotion targeting university students and creati-ng whole systems (7,9,15,17 –22,27). An example of initiatives influenced by the HPU/healthy universities is the Healthy Trinity (25). The FISU Healthy Campus program is another initiative that has recruited at least 130 universities from 39 countries with a few from Africa (29). Although not affiliated with the IHPU, FISU is arguably an HPU as it implements many aspects of the concept, including the whole systems approach. The university sports centers were found to be at the core of HPU initiatives, understandably so because of their focus on high-performance parti-cipation and health promotion. In some universities, faculties of health sciences and sustainable settings are responsible for the HPU initiatives (29).

Bibliometric analysis of the organizations working on the HPU

Twenty-eight (n = 28) articles were selected and analyzed using VOSviewer Bibliometrics analysis. These articles included 21 that met the inclusion criteria for the integrative review and seven (7) that met at least one action area of the HPU concept (Figure 1). One (1) report from the ini-tially selected articles (n = 22) did not meet the supported file format for the VOSviewer. The lines in Figure 2 refer to the link strength between the organizations and the dots represent the density of the link. The bigger the dots the more the density and vice versa.

Figure 2.

Network and density analysis of universities focusing on the HPU concept.

We sought to establish the locations of the organizations working on the HPU concept to determine in which geographical part the HPU concept discourse is mainly popular. A network and density analysis was performed, and the results showed that 27 organizations from the selected studies focused on the HPU concept or related. Only nine (8) organizations had the greatest tot-al link strength with each other, indicating the relationship/collaboration and or co-authorship between researchers working on the HPU concept. These organizations shown in Figure 2 and Table 2 are mainly from Europe – Sweden, United Kingdom, Norway, Switzerland and Austria. The health and social sciences departments are at the forefront of researching the HPU concept. Only one university, the University of Central Lancashire, has a ‘health and sustainable settings’ department, as shown in Figure 2 and Table 2.

Table 2.

Key for the abbreviations in Figure 2.

Abbreviation/center	University
martin springer center for con	Ben Gurion University
ntnu center for health promoti	Norwegian University of Science and Technology
department of health promotion	University of Bergen, Norway
department of health and socia	University of West England, Bristol, UK
ntnu center for health promoti	Norwegian University of Science and Technology
healthy & sustainable settings	University of Central Lancashire
who-cc health promotion in hos	Ludwig Boltzmann Institute of health promotion
division of public and organiz	University of Zurich, Switzerland
department of health sciences	University of West Trollhattan, Sweden

Source: VOSviewer Bibliometric software.

We also conducted a network analysis of common terms from the 28 articles (Figure 3). The lines represent the network or link among the common words, and the dots indicate the density. The bigger the dots, the denser the common word. Likewise, the more the word occurs, the more links (lines) it has with other words. The results were 20 terms, including initiative, context, stu-dy, community, action, research, healthy universi-ties, settings approach and health promoting uni-versities. The term study had the highest total link strength, with 16 links and 83 occurrences, as shown in Figure 3. The implication might be that the healthy universities/HPU discourse is gaining global momentum. It is also interesting to confirm the interchangeability of the HPU terms and the use of the whole systems approach as an unde-rpinning philosophy. It is worth noting that interviews are commonly used in studies related to health promotion among university students. Terms like initiative, community, context, action, understanding and practice are indications that the HPU discourse is developing globally and has diverse semantical, cultural and contextual considerations.

Figure 3.

Network analysis of common terms.

Five contextual challenges of the HPU

Definition

The foremost challenge in evaluating the status of the HPU concept is the definition/semantics and the context of the HPU concept itself, as it is apparent that the HPU network influences a fraction of global universities whilst many focus on health promotion interventions. Dooris et al. (18) assert that there are still challenges in translating the rhetoric of the whole systems approach into action with large, complex and culturally diverse organizations. They also alluded to the fact that the HPU is a truly global movement on four continents. This is also supported by the growing list of HPU initiatives and networks in Australia, and New Zealand, and the interest from African universities (9,23,25,26,29). According to Suárez-Reyes et al. (24), HPU initiatives exist worldwide, yet infor-mation on how universities translate the HPU concept into actions is scarce.

Thus, evaluations of the current status of the HPU concept are possible by first understanding the dynamics and semantics that apply to the discourse. The first dynamic is that the HPU is semantically a concept used or applied to improve health among university students. At the same time, the concept is also officially a program owned by the IHPU network of universities − with several HPU networks affiliating (3). Universities do not necessarily have to be part of the HPU network of universities to implement the HPU concept, espe-cially if they have political support from university authorities, a coordination structure, funding and collaboration (21). These factors were found to be influencing the HPU concept in a study by Suár-ez-Reyes et al. (24). However, affiliating with one of the IHPU networks can lead to better delivery of the action and item areas, coordination and collaboration (10).

Theorization of the HPU

Secondly, components of the HPU concept are cross-cutting and evident in many intervention programs, including the whole systems approach and healthy universities (21). The whole systems approach is the most common framework imple-mented by HPUs globally – which promotes a wholesome focus when targeting interventions for promoting health among university students (2,9,13,20 –22,24). Most of the interventions are influ-enced by the Ottawa Charter, the socioecological approach, and salutogenesis, among others (22). Theorization of the HPU concept is thus clear to investigate, but the impact depends on many factors depending on which health-promoting approach is being followed and which HPU net-work is affiliated.

Measurement of the HPU concept

Thirdly, measurement of the HPU concept can be done with regard to the number of universities in the HPU network/number of universities implementing the HPU concept (11) or through reviews (qualitatively) to measure the impact of interventions, whole systems approach and other programs. However, measuri-ng the growing number of universities in the HPU network is not enough to prove the impact of interventions but, rather, a holistic analysis of the different global concepts universities use. For instance, most African universities are not part of the HPU network (9), though some of these universities can be regarded as health-promoting universities based on whole systems approach or other intervention pro-grams/initiatives. Global scholars have used various measurement tools (7,17), mainly questionnaires, interviews and photovoice. Still, they have concentrated mainly on universities from four continents. Results from the bibliometric analysis show that most of the institutions working on the HPU concept are in Europe and, thus, not reflective of global institutions or universities. It appears, though, that the impact of interventions has been explored in individual countries like Ireland (Healthy Trinity), the United Kingdom (UK self-review tool), Latin America, Australia and New Zealand, among others, rubberstamping the need for an HPU network and HPU initiative existent in all the continents. (7,16,23,26,27).

Coordination of the HPU concept

The fourth challenge is that some HPU initiatives have the political support of the university auth-orities and national or regional networks, whilst some do not (14,23,26). In the absence of political support, some universities may not be technically classified as HPUs, hence the difficulty in measuring the implementation of the HPU. The bibliometric analysis revealed that the HPU concept is coordinated by specific departments, especially in health sciences and sports science. This was also confirmed in a study by Bachert et al. (12). However, what is novel is that the study revealed the University of Central Lancashire as having a specific department tailored to suit the operations of the HPU/healthy universities, namely, the Department of Health and Sustainable Settings. This is very interesting as the HPU is mainly centered on the whole settings approach (2,9,11,13,15,17,18,20,22,27,29). The university’s website states:

‘Established in 2001, the Healthy and Sustainable Settings Unit aims to support the holistic and integrated development of healthy settings – acknowledging that “health is created and lived by people within the settings of their everyday life; where they learn, work, play and love” (WHO, 1986) and that many health challenges are interrelated and can be best tackled through comprehensive, integrated programmes in the contexts and places where people live their lives.’

It is interesting to note that one of the top authors of the HPU concept, Mark Dooris, is the coordina-tor of the center and co-chair of the UK Healthy Universities Network, which has advanced in pro-moting the whole settings approach. This is a pra-ctical example of how academics help shape theo-retical frameworks for the HPU concept in their regions and coordinate the implementation and evaluation of the concept.

Methods for researching the HPU concept

Methods used for evaluating the status of the HPU concept globally may determine the type of results extracted, which may not be a true reflection of the HPU status. This study unearthed new methods that can be used in the discourse of the HPU concept, including photovoice, network analysis, ethnographic research, and traditional interviews, systematic and integrative literature reviews. The photovoice method attaches images of campus settings to the students’ voices, enabling researchers to get better insight into the relationship between the campus settings and the healthy behaviors of the students (17). The photovoice can complement ethnographic research such as direct observation and network analysis. Most interesting is that we used Bibliometric analysis and VOSviewer as a novel and innovative method for further un-derstanding the dynamics of the HPU discourse, including the authors involved and their locations and networks, and to establish the depth of the concept. This method allowed us to include some other articles that did not fully meet the inclusion criteria – one advantage over systematic and integ-rative reviews. More interestingly, the FISU Healthy Campus Best Practices e-book (29) provides another holistic method for evaluating the status of HPUs globally.

Recommendations and implications for emerging African HPUs

We recommend that universities, globally and specifically in Africa, establish a health and sus-tainable settings department that oversees the imp-lementation of the HPU concept within and outside their institutions which is fully acknowledged and funded by university authorities. A case of reference is the sustainable settings department at the Uni-versity of Central Lancashire in the United Kingdom. It is paramount that African universities affiliate with the HPU networks globally to take advantage of the support and expertise of the members of those networks. An example has also been set by the University of Johannesburg (South Africa), Chinh-oyi University (Zimbabwe) and Makerere University (Uganda), which are part of the FISU Healthy Campus program (29). Universities must also con-sider expanding their influence regarding the HPU to the macro environment to play a leading role in the whole settings approach. This study, therefore, provides a reference source for African universities to help them become an HPU through university political leadership, network affiliation, theorization, coordination, evaluation, and implementation of initiatives.

Conclusion

The HPU concept is gaining momentum globally, as evidenced by the growing list of universities (HPU network) involved and the proliferation of interven-tions/initiatives targeting university students. How-ever, the concept’s conceptual understanding varies depending on the diverse affiliations and beliefs of the HPU concept. It is contextually challenging to ‘package’ the concept as implementation differs acc-ording to a plethora of influences, including theori-es and models and the dynamics surrounding the definition and understanding of the HPU concept. Global interventions are highly influenced by national, regional or continental networks working on the HPU concept. The impact of the networks is pragmatically difficult to ascertain if the assessment is to go beyond the number of affiliating universities. However, it is undisputed that the status of the HPU concept is positive, and the advantages of implementing it glo-bally are of paramount importance. Universities glo-bally may take advantage of the various HPU net-works and initiatives available in their countries or regions to implement the HPU concept effectively. African universities have available networks such as the FISU Healthy Campus to register and gain from the support, collaborations, implementation and evaluation of their HPU programs.

Limitations

The selected studies were mainly those that explicitly referenced the HPU concept or similar. Other studies addressing certain aspects of the HPU concept may have been excluded. However, the limitation was counteracted by the Bibliometric analysis, which allowed for the inclusion of some other articles that partially met the inclusion criteria.