A decade on: exploring the Okanagan Charter’s continued international relevance for health promotion in higher education

Abstract

Over the past decade, the Okanagan Charter has guided health promotion in higher education, but shifts in the sector have raised questions about its ongoing global relevance. This study explored international stakeholder perspectives on the Charter’s applicability and identified priority areas for potential revision. An anonymous, cross-sectional survey was developed on Qualtrics and distributed internationally via purposive sampling. The survey included 19 ordinal-scale questions, each paired with a related open-ended question and demographic questions. Quantitative data were analysed descriptively and with independent samples t-tests, while qualitative data were examined using Braun and Clarke’s reflexive thematic analysis. A total of 488 participants from 48 countries responded (English, n = 455; Spanish, n = 43). The majority were aged 35–44 years (28%) and 71% identified as female. Respondents held diverse and often multiple roles, including health and well-being professionals (42%), academics (33%), administrators (26%), and students (9%). Collectively, 1951 comments were submitted. Among the participants who completed all 19 questions exploring the relevance of each Charter component (n = 330), 77.3% recommended revising at least one area. Four overarching thematic areas were identified: evolving contexts and concepts, leadership and governance, implementation and evaluation, and language syntax and comprehension. While the Okanagan Charter remains a valued document, most respondents advocated for targeted revisions to better reflect the evolving needs of higher education. These findings highlight key areas for consideration in any future iteration and underscore the importance of continued global dialogue to support healthier campus environments.

Graphical Abstract

Graphical Abstract.

Contribution to Health Promotion.

• Previous research has identified higher education is a critical yet underleveraged setting for global health promotion.

• While the Okanagan Charter remains valued, stakeholders identified key areas for advancing the global health promoting campuses agenda.

• There is a strong call for clearer language, stronger direction, and meaningful accountability mechanisms that reflect evolving higher education contexts globally.

Introduction

The Health Promoting Universities movement began in the mid-1990s as part of the health-promoting settings approach (Dooris 2001a). It built on the Ottawa Charter and Health for All initiatives to foster health, well-being, and sustainability across higher education institutions (Dooris 2001a). The movement was formalized through the publication of the Okanagan Charter (Okanagan Charter 2015) at the 2015 International Conference for Health Promoting Universities and Colleges (later termed the International Health Promoting Campuses Conference). The Okanagan Charter built on the Ottawa Charter for Health Promotion by translating its key areas for action (advancing health-supportive policy, fostering environments conducive to well-being, strengthening collective and community engagement, enhancing individual capacities, and shifting institutional systems towards health-oriented practice) into the higher education context. It also extended the Edmonton Charter for Health Promoting Universities. While the Edmonton Charter for Health Promoting Universities articulated guiding principles for health-promoting universities, the Okanagan Charter advanced this work by structuring health promotion around a vision and aspirations, three overarching purposes, two calls to action (operationalized through eight subactions), and eight guiding principles (World Health Organisation 1986, 2005, Okanagan Charter 2015). It further positioned higher education institutions (HEIs) as active contributors to advancing equity, sustainability, and global responsibility (Okanagan Charter 2015). It called on HEIs to ‘embed health into all aspects of campus culture, across the administration, operations, and academic mandates, and lead health promotion action locally and globally’ (Okanagan Charter 2015). A decade since its launch, the Okanagan Charter has been translated into eight languages (English, Bulgarian, French, German, Spanish, Irish, Chinese, and Turkish), and many HEIs worldwide have adopted, endorsed, and used it as a guiding document for health promotion (Squires and London 2022, Dietz and Schäfer 2023). In addition, many countries have established national frameworks and health-promoting campus networks aligned with the vision and calls to action of the Okanagan Charter (Higher Education Authority 2022).

However, global enrolment in HEIs has more than doubled between the years 2000 and 2020, positioning HEIs as increasingly influential settings for population health promotion (Sáenz et al. 2025, UNESCO 2025). Persistent and emerging health issues have highlighted the need for coordinated health promotion efforts at all levels of the higher education system (Dooris et al. 2021). Students in higher education have been reported to experience mental health difficulties, patterns of unhealthy diets, excessive sedentary time, risky alcohol consumption, and the problematic use of electronic nicotine delivery systems and cigarettes (Wicki et al. 2010, Castro et al. 2020, Deressa Guracho et al. 2020, Sheldon et al. 2021, Ahmadi et al. 2024, Albadrani et al. 2024). Furthermore, higher education employees have been reported to experience high levels of work-related stress and burnout, driven by performance satisfaction, and commitment difficulties (Khan et al. 2019). These challenges have significant implications not only for individual well-being but also for academic performance, productivity, and quality of education (Aloka 2022).

Higher education provides students with opportunities to explore their values, grow as global citizens, and equip themselves for future responsibilities in their communities, workplaces, and societies at large (Newton et al. 2016). The sector as a whole also has the potential to drive transformative social, economic, and environmental change at local, national, and global levels (Brennan et al. 2004). The role of higher education as a key setting for health promotion involves shared responsibility across leadership, employees, students, and partners to influence health, well-being, and sustainable behaviours for all (Tsouros et al. 1998, Dooris 2001b, Sanci et al. 2022). The Health Promoting Universities movement highlights this role, emphasizing the need for guiding documents that remain relevant, actionable, and responsive to global health agendas, such as contributing to the advancement of the Sustainable Development Goals (SDGs) (Dooris 2001b, Franco et al. 2019).

However, the HEI context is rapidly evolving. Key transformations include the rise of blended and digital learning (Mestan 2019), changes in academic structures and governances (Saykılı 2019), and growing institutional responsibilities related to sustainability and climate action (Leal Filho et al. 2021). HEIs are also under increasing pressure to demonstrate crisis preparedness and resilience in response to global health, environmental, and geopolitical challenges (Ul Hassan et al. 2025). These developments raise questions about whether existing health promotion charters and frameworks remain fit for purpose in supporting a salutogenic approach, which addresses all persons along the health continuum and focuses on factors that promote well-being (Antonovsky 1996), as well as equity-focused approaches within increasingly complex HEI systems. Additionally, global perspectives, including the SDGs, planetary health, and the increasingly recognized One Health framework, highlight the interdependence of humans, animals, plants, and the wider environment, promoting approaches that advance health, sustainability, and equity across socioecological systems (Dooris 2001b, Franco et al. 2019, Winkler et al. 2025).

Despite widespread adoption, the Okanagan Charter has not been systematically examined in relation to how well its components remain fit for purpose given these transformations. The project was implemented across several interconnected but distinct phases: (i) international surveys exploring perspectives on the relevance of the Okanagan Charter in today’s context and an exploration of ‘what’ areas should be addressed in the future, (ii) in-depth interviews and focus groups gathering collective opinions and expert recommendations on ‘how’ the current needs and challenges can be addressed in a new document, and (iii) a multistage drafting process with the aim of collectively developing a new document that is relevant, accessible, and globally implementable. This manuscript documents the first phase of the project, which collectively led to the development of the Limerick Framework for Action: Advancing the Global Health Promoting Campuses Agenda (International Health Promoting Campuses Network and University of Limerick 2025).

This study explores international stakeholder perspectives on whether the Okanagan Charter remains relevant in today’s higher education context or requires revision or redevelopment and identifies stakeholder views on what areas should be addressed if revisions are needed. Using a mixed-methods survey, it identifies priority areas for potential redevelopment to better support health promotion within increasingly complex HEI environments. The lead-up to the 2025 International Health Promoting Campuses Conference, hosted by the University of Limerick in collaboration with the International Health Promoting Campuses Network (IHPCN), provided a timely platform for global dialogue and to catalyse collaboration. The conference brought stakeholders together to share insights and strengthen collective action.

The IHPCN is a global alliance of national (e.g. German Network of Health Promoting Universities) and regional health-promoting campus networks (e.g. Ibero-American Network of Health Promoting Universities comprises 16 national networks covering Brazil, Chile, Columbia, Costa Rica, Cuba, Ecuador, Mexico, Peru, Puerto Rico, Spain, and Central America/Caribbean), guided by two cochairs and a steering group of network leaders. The IHPCN supports institutions in embedding health, well-being, and sustainability into higher education with leaders and members facilitating international collaboration, conferences, and shared resources to advance the Okanagan Charter and movement worldwide.

Materials and methods

Context and survey design

Strategic collaboration was established with the IHPCN to ensure global relevance and alignment with the preparatory work for the 2025 International Health Promoting Campuses Conference at the University of Limerick. To support the research process, a Working Group was convened with advisory input from the IHPCN. The Working Group comprised 14 members selected for their diverse geographical and professional expertise. Many members held multiple roles, and areas of expertise spanned a wide range across health (e.g. mental health, health behaviours, health promotion policy, and leadership). In terms of gender, 85.7% (n = 12) identified as female. Students represented 14.3% (n = 2), 42.9% (n = 6) were academic/faculty, and 14.3% (n = 2) were health and well-being coordinators. Most members were affiliated with a higher education institution (78.6%; n = 11), while the remaining (21.4%; n = 3) were affiliated with global health organizations. Members were purposefully invited to ensure balanced representation across regions and sectors. The group operated under a term of reference document, which outlined its objectives, scope, roles, responsibilities, and anticipated contributions to the research.

The wider research initiative was organized into multiple phases: (i) an internationally distributed survey designed to capture views on the contemporary relevance of the Okanagan Charter, (ii) in-depth interviews and focus groups conducted to gather shared perspectives and expert guidance on how emerging needs and challenges could be addressed within a revised document, and (iii) a multistep cocreation process of a new document based on findings from phases (i) and (ii). The present paper focuses on the first phase of the process. In alignment with participatory health research and cocreation principles, the study actively engaged stakeholders throughout all phases of the research process. By promoting inclusive dialogue and collaborative decision-making, the study sought to ensure that outcomes were contextually relevant and aligned with the lived experiences, priorities, and expertise of those most affected.

To enhance accessibility and inclusivity, the survey was translated into Spanish and distributed across Spanish-speaking networks, mirroring the multilingual approach used during the Charter’s original development (Black and Stanton 2016). There was no predetermined target sample size as this study was exploratory in nature. Output summaries were recorded on a biweekly and monthly basis to monitor developing patterns and identify representativeness and the point of data saturation. In this study, data saturation was considered reached when additional responses or participant input no longer generated new themes, codes, or insights relevant to the research questions. The survey was open from 26 November 2024 to 30 April 2025.

The survey was initially drafted in Microsoft Word and finalized on Qualtrics Survey Software (Qualtrics Provo UT 2025), after incorporating feedback from the piloting process. The survey was administered through English and Spanish and took ∼15–20 minutes to complete, which depended on the knowledge and experience of the respondent within the field.

Participants and procedure

Purposive sampling was employed to maximize representativeness and ensure inclusion of diverse stakeholder perspectives. Inclusion criteria were one or more of the following categories: (i) individuals with evidence of expertise in health promotion in HEI settings, (ii) individuals with expertise in the development of charters in HEIs, (iii) individuals with evidence of leadership in health promotion, and (iv) representation from all HEI sectors, including employees, undergraduate students, and postgraduate students. In addition, we also recruited individuals with additional relevant expertise (e.g. sustainability, equality, diversity, and inclusion). Participants were excluded if they were <18 years of age. Participants’ responses were excluded from analysis if they completed <12% of the survey, as this threshold corresponded to the first primary outcome variable of interest (the charter vision).

The survey was initially distributed to the cochairs of the IHPCN and the lead representatives of the regional and national networks. They were provided with a recruitment letter and invited to share it with the survey link and QR code with their network members. Similarly, the survey and recruitment letter were shared with the Working Group, local organizing committee, and the scientific committee of the 2025 conference. Following this, the survey was distributed to student associations, attendees of the 2015 International Conference on Health Promoting Universities and Colleges conference, those involved in developing the Okanagan Charter, the International Association of Public Health Institutes, and those who expressed interest or registered for the 2025 conference.

Ethical considerations

Participation was anonymous and voluntary. Participants received an information sheet, a consent form, and a short explanatory video outlining the survey’s purpose and the Charter’s components. Ethical approval was granted by the University of Limerick Education and Health Sciences Research Ethics Committee (2024_06_17_EHS).

Outcome measures

Survey items were developed specifically for this study, as no existing validated instrument captured the full scope of the research objectives. There were 19 items that mapped directly to the Charter’s key components, including its vision, aspirations, three purposes, two calls to action, eight subactions, and eight guiding principles. Participants were asked to evaluate each component using a four-point scale: (i) retain unchanged, (ii) revise with minor adaptations, (iii) revise with major adaptations, or (iv) remove. Open-text responses were solicited for any suggested changes.

The final section on the survey collected demographic information, including participants’ roles, health-promoting campus network affiliations, primary country of residence, gender identity, and age category. At the end of the survey, they were asked if they would be interested in being involved in follow-up interviews, in which case, they could provide their details (see Supplementary Table S1).

Data analysis

The results from the quantitative variables were analysed using frequencies and percentages and presented in tables and figures. Independent samples t-tests were used to investigate demographic differences between genders. Data were initially exported to IBM Statistical Package for the Social Sciences (SPSS) version 29.0 for analysis (IBM SPSS Inc. Armonk 2024). All responses for the English and Spanish variables were merged into a single dataset.

Qualitative data were analysed using reflexive thematic analysis following the six-step approach outlined by Braun and Clarke, which included (i) data familiarization, (ii) data coding, (iii) initial search for themes, (iv) reviewing themes, (v) defining and naming themes and (vi) producing the report (Braun and Clarke 2006). This method was selected for its suitability in exploring complex, context-dependent perspectives without requiring a predefined coding framework (Braun and Clarke 2021, Humble and Mozelius 2022). Thematic analysis enabled the identification of patterns across the entire dataset and facilitated interpretation of international stakeholder views on the Charter’s relevance and areas for potential revision. Rather than analysing responses by question, the data were treated as a cohesive corpus to allow for cross-cutting thematic development (Braun and Clarke 2006).

A two-step approach was used to code answers to the open-ended questions in the Spanish survey. Firstly, the lead author (A.N.) translated all Spanish open responses to English. A.N. and K.M. were then both able to contribute to the analysis of the translated Spanish data in English. This approach has been shown to yield high-quality insights in cross-cultural survey research (Scholz et al. 2022). During data familiarization, two independent coders (A.N. and K.M.) read all open-ended responses and recorded preliminary observations. Initial coding followed, with both coders independently coding a sample (first 10 responses in the ‘vision and aspirations’ section) to ensure comprehensive coverage rather than consensus. Using an inductive, semantic approach, each then independently coded ∼70% of dataset; the other 30% were coded by one coder. Codes were compiled in a shared spreadsheet, and a sample was reviewed by C.B.W., C.N., and A.T. A.N. and K.M. collaboratively grouped similar level one codes into level two, which were further grouped into level three. This process yielded 33 initial themes, which were subsequently consolidated into four overarching thematic domains (level four). The themes were reviewed and refined with input from C.N., A.T., and the Charter Working Group.

Integration of the mixed-methods findings occurred during interpretation, with qualitative themes considered alongside quantitative results. This approach informed the discussion and recommendations, with statistical outputs complementing patterns of alignment, nuances, and complexities across stakeholder perspectives.

Reflexive statement

The coding team comprised white, female-identifying researchers based at the University of Limerick. We recognize that our professional backgrounds and prior involvement with the Okanagan Charter and the 2025 conference may have influenced interpretation. Ongoing reflexive dialogue within the team and with the Working Group supported critical reflection and data-grounded thematic development.

Results

The final sample comprised 488 participants (responses in English n = 445; Spanish n = 43) from 48 countries. A total of 331 participants (68%) completed the full survey. A breakdown of responses by country is provided in Table 1. The most frequently reported age category was 35–44 years (28%), with 71% identifying as female, 25% as male, and 2.5% as ‘other’ or ‘prefer not to say’. Participants could select multiple roles, with 33% reporting as academic/faculty, 26% administrators/professional services, 42% health and well-being professionals, 12% researchers, 12% senior leaders, 5% undergraduate students, 4% postgraduate students, and 4% ‘other’. ‘Other’ included local government councillors, university recreation employees, network coordinators, and higher education leaders. Regarding awareness and affiliation, 74% (n = 239) of respondents had heard of the IHPCN, and 82.9% (n = 268) reported affiliation with a regional health promotion network in higher education. Concerning the Okanagan Charter, 32.9% (n = 107) identified as signatories, 32.3% (n = 105) as nonsignatories, 31.1% (n = 101) were unsure, and 3.7% (n = 12) indicated that it was not applicable.

Table 1.

Frequency and distribution of responses.

Frequency (%)	Africa	Asia	Europe	North America	Oceania	South America
Continent of residence N = 306	15 (4.9%)	20 (6.5%)	100 (32.7%)	150 (49.0%)	9 (2.9%)	12 (3.9%)
Countries represented Total N  = 48	6 (12.3%)	8 (16.7%)	18 (37.7%)	9 (18.7%)	2 (4.2%)	5 (10.4%)
Gender N = 313
Male n  =  79 (25.2%)	7 (8.9%)	12 (15.2%)	23 (29.1%)	34 (43.0%)	2 (2.5%)	1 (1.3%)
Female n  =  223 (71.2%)	8 (3.6%)	9 (4.0%)	80 (35.9%)	108 (48.4%)	7 (3.1%)	11 (4.9%)
Other n  =  11 (3.5%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	11 (100%)	0 (0.0%)	0 (0.0%)
Age N  = 308
18–24 years n  = 14 (4.5%)	2 (14.2%)	0 (0.0%)	6 (42.9%)	6 (42.9%)	0 (0.0%)	0 (0.0%)
25–34 years n  = 30 (9.7%)	2 (6.7%)	2 (6.7%)	13 (43.3%)	10 (33.3%)	3 (10.0%)	0 (0.0%)
35–44 years n  = 89 (28.9%)	4 (4.5%)	2 (2.2%)	31 (34.8%)	44 (49.4%)	3 (3.4%)	5 (5.6%)
45–54 years n  = 83 (26.9%)	3 (3.6%)	8 (9.6%)	26 (31.3%)	44 (53.0%)	1 (1.2%)	1 (1.2%)
55–64 years n  = 72 (23.4%)	3 (4.2%)	7 (9.7%)	23 (31.9%)	34 (47.2%)	1 (1.4%)	4 (5.6%)
65 + n  = 16 (5.2%)	1 (6.2%)	2 (12.5%)	3 (18.8%)	9 (56.3%)	0 (0.0%)	1 (6.2%)
Prefer not to disclose n  = 4 (1.3%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	2 (50.0%)	1 (25.0%)	1 (25.0%)
Role/expertise
Academic/faculty n  = 106	3 (2.8%)	13 (12.3%)	36 (34.0%)	44 (41.5%)	2 (1.9%)	8 (7.5%)
Administration/professional services n  = 86	5 (5.8%)	7 (8.1%)	21 (24.4%)	52 (60.5%)	1 (1.2%)	0 (0.0%)
Community governmental/nongovernmental n  = 13	2 (15.4%)	3 (23.1%)	6 (46.2%)	2 (15.4%)	0 (0.0%)	0 (0.0%)
Health and well-being professional n  = 131	6 (4.6%)	6 (4.6%)	27 (20.6%)	80 (61.1%)	5 (3.8%)	7 (5.3%)
Researcher n  = 38	3 (7.9%)	3 (7.9%)	17 (44.7%)	12 (31.6%)	2 (5.3%)	1 (2.6%)
Senior leadership n  = 35	2 (5.7%)	5 (14.3%)	6 (17.1%)	20 (57.1%)	0 (0.0%)	2 (5.7%)
Undergraduate student n  = 13	2 (15.4%)	0 (0.0%)	7 (53.8%)	4 (30.8%)	0 (0.0%)	0 (0.0%)
Postgraduate student n  = 13	0 (0.0%)	0 (0.0%)	6 (46.2%)	6 (46.2%)	1 (7.7%)	0 (0.0%)
Other n  = 14	1 (7.1%)	0 (0.0%)	5 (35.7%)	8 (57.1%)	0 (0.0%)	0 (0.0%)

Of the signatories, 14 (14.3%) reported partial integration of the charter within their institution, 71 (72.4%) reported moderate integration, and 13 (13.3%) reported full integration. Additionally, 81 respondents (24.8%) had prior involvement in a charter development process.

Quantitative findings

A total of 1951 suggestions for revising the Charter were recorded. Among those who completed all 19 items on the key component areas (N = 330), 77.3% made suggestions in at least one area, 64.2% in two or more, and 54.8% in three or more. An independent samples t-test revealed no significant difference in the number of suggestions submitted between male and female respondents [t (312) = 0.058; P = .954], with a mean difference of 0.031 [95% confidence interval: (−1.03, 1.10)].

Across the vision, aspirations, and purpose sections, over half of participants recommended retaining the existing content. However, 28.8% suggested revisions to the vision, 31.8% to aspirations, and 35.1% to the purpose. The number of qualitative suggestions submitted was 123 (vision), 130 (aspirations), and 121 (purpose).

For the eight calls to action (1.1–1.5 and 2.1–2.3), the highest support for ‘remain unchanged’ was in Call 2.3 (83.1%) and the lowest in Call 1.2 (69.6%), with revision suggestions ranging from 16.3% to 30.3% and qualitative comments from 60 to 111 per call to action.

Among the seven principles, the percentage of ‘retain unchanged’ responses ranged from 72.9% for Principle 7 to 83.9% for Principle 4. Revision suggestions ranged from 15.4% to 26.2%, with few suggesting removing the principles section from the document (1.6%). Qualitative suggestions per principle ranged from 52 to 89.

Additionally, 129 respondents (31.7%) identified missing key purposes, 95 (27.6%) noted missing calls to action, and 98 (31.5%) highlighted missing principles.

Qualitative findings

Four themes were derived from the thematic analysis of the qualitative comments within the survey. These were (i) expanding the scope to include contemporary contexts and concepts, (ii) health promotion leadership and governance, (iii) implementation and evaluation, and (iv) language syntax and comprehension. Each theme comprised multiple subthemes (Fig. 1). Each theme captures participants’ perspectives on the current relevance and future direction of the Okanagan Charter.

Figure 1.

Themes and subthemes identified from thematic analysis.

Theme one: expansion to include contemporary contexts and concepts

This theme reflects respondents’ view that the Charter must evolve to remain relevant in a rapidly changing global landscape. Contemporary contexts refer to the external conditions shaping health and higher education today, such as shifting political environments, emerging global health challenges, commercial influences, and the sociocultural realities of 2025. In contrast, contemporary concepts refer to the ideas, frameworks, and approaches that have gained prominence in recent years, including equity-focused terminology and planetary health. Together, respondents argued that both the changing context and the rise of new concepts require the Charter to broaden its scope, modernize its language, and address issues that were less visible a decade ago.

Expanding the scope of the charter to address emerging challenges

Respondents highlighted the need to renew the Charter to reflect global health challenges that have emerged over the past decade. They stressed the importance of addressing current and future health-related needs in higher education. Many advocated for expanding the Charter’s scope to include broader health topics. Several called for greater focus on health equity and social justice: ‘Make a call out to DEI (diversity, equality, and inclusion) initiatives; I would add EDIDR (Equity, Diversity, Inclusion, Decolonization and Reconciliation), or just EDI, into this statement’ (academic/faculty, Canada, female). Others urged that planetary health and sustainability be more emphasized: ‘While the health and sustainability of our planet is still paramount, I do feel that we can broaden our scope/vision to include more of what is plaguing our planet’ (health/well-being professional, USA, female). Several participants also cautioned that revisions should consider differing political and cultural contexts. ‘May need to revise the wording to comply with current administrations destruction of the Diversity Equity and Inclusion practices and policies. This does not mean that we cannot continue to do the work that we do. It is not the wording that defines what we do, but the actions that we put behind them’ (health/well-being professional, USA, female).

Updating to address the 2025 context

Respondents outlined the evolving 2025 context, including the need to address commercial influences on health: ‘Include something here on commercial determinants of health and minimizing the harmful impacts of commercial industry actors’ (health/well-being professional, Ireland, female). Another participant wrote: ‘The models that are developed for the training of professionals in higher education institutions have adapted to the new needs of the professional and labour fields, as well as the context and the needs that demand changes in the models to adapt them to the new contemporary reality’ (academic/faculty, Ireland, male).

Additional concepts need to be incorporated

Several concepts were identified for inclusion that had not previously been in the charter or needed increased incorporation. ‘Consider how psychological safety, equity, accessibility, and decolonization can be incorporated’ (administrator/professional services, Canada, female). Others encouraged ‘incorporating One Health approaches’ (academic/faculty, Cyprus, male) and ‘prevention-focused, multidisciplinary strategies’ (academic/faculty, Hong Kong, male) to reflect global complexities.

Theme two: health promotion leadership and governance

This theme captures respondents’ views on the importance of establishing strong, coordinated leadership and governance structures to advance health promotion within higher education. Leadership here refers to the individuals and groups, such as students, employees, administrators, and senior decision-makers, who guide, champion, and influence health promotion efforts. Governance, in contrast, refers here to the systems, structures, policies, and institutional commitments that enable these efforts to be organized, supported, and sustained over time. Respondents emphasized that both effective leadership and robust governance mechanisms are essential to embedding health promotion as a core institutional priority. Together, they determine not only who drives the work but also how it is resourced, implemented, and aligned with broader social and institutional goals.

Emphasize the role of leadership

Respondents emphasized the importance of integrating leadership into the revised document to support meaningful and sustainable health promotion outcomes. They highlighted the need for strong leadership at all levels. As one participant stated: ‘the role of leadership in accomplishing this is key. Can we include something about leadership?’ (academic/faculty, senior leadership, Canada, female). Others highlighted the need to emphasize the role of students as future leaders: ‘educating the upcoming opinion leaders as multiplier for more sustainable societies’ (senior leadership, Germany, gender not specified).

Need for supportive structures

Supportive structures were also reported, including the need for resources, dedicated teams, and enabling policy frameworks: ‘Ensure that resources are developed or aligned in support of the creation of health on campus and in the local community’ (administrator/professional services, USA, female). Respondents stressed that universities must commit infrastructure and support to implement health promotion effectively with one suggesting a sentence including the following: ‘Establish the foundational rationale for developing the requisite infrastructure needed to elevate health promotion as an essential process in creating health and sustainability within University and College systems and settings’ (health/well-being professional, researcher, senior leadership, USA, female).

Prioritizing inclusivity, equity, and systemic change

Participants highlighted the need for health promotion to prioritize inclusivity, equity, and systemic change. As one respondent stated: ‘There is limited focus on inclusivity and equity, which are critical for addressing systemic health disparities in higher education settings’ (academic/faculty, Thailand, female). Another suggested: ‘Incorporate an explicit commitment to addressing systemic inequities, ensuring health promotion efforts prioritise marginalised and underserved populations on campus and beyond’ (academic/faculty, Ireland, female).

Bridging health promotion efforts for greater reach

Respondents also emphasized the importance of aligning health promotion efforts with wider communities. One participant noted: ‘Universities and colleges promote health not just for individuals but for communities and the environment’ (academic/faculty, health/well-being professional, senior leadership, Brazil, female). Another highlighted the need to connect the Charter to broader global goals, stating: ‘Recognising the intersection of health, equity, and sustainability aligns with global priorities, such as the United Nations Sustainable Development Goals (SDGs)’ (academic/faculty, Ireland, female).

Theme three: implementation and evaluation.

This theme reflects respondents’ emphasis on the need for clear, sustained, and accountability-focused processes to support the implementation and to evaluate its impact over time. They referred to practical actions, structures, and strategies institutions put in place to advance health promotion and measurement, monitoring, and feedback mechanisms that help determine whether these actions are effective, equitable, and aligned with the intended goals. Respondents viewed both elements as essential: implementation ensures the work happens, while evaluation ensures the work is meaningful, evidence informed, and continuously improving.

Monitoring and improving health promotion action

The importance of monitoring and improving health promotion action was widely acknowledged. Participants called for a focus on ‘continuous quality improvement’ (administrator/professional services, Canada, female) to support regular progress checks, assess effectiveness, and allow institutions to adapt their approaches over time.

Accountability of the charter

Ensuring accountability of the Charter was another key concern. Respondents emphasized the need for evaluation mechanisms that hold institutions responsible for their commitments. One participant noted: ‘This is great, but I think this needs to name something about ensuring mechanisms for feedback and regular evaluation’ [health/well-being professional, student (postgraduate), Canada, genderfluid]. Internal and external assessments were seen as crucial to maintaining the Charter’s integrity and driving long-term impact.

Need for practical guidance

Many respondents also stressed the need for practical guidance for action. The Charter’s current language was described as aspirational but lacking in direction. As one participant explained: ‘The current Charter language is quite lofty without adequate practical guidance and examples. With ten years to draw from, a revised Okanagan Charter can provide a toolkit of applied practice examples from a range of nations’ (health/well-being professional, senior leadership, USA, female).

Capitalizing on strengths

Lastly, participants encouraged an asset based and salutogenic approach. One wrote: ‘Build on strengths: Adopt an asset-based and salutogenic approach that recognizes and leverages existing strengths, understands challenges, celebrate successes, and shares lessons learned. Foster continuous opportunities for the enhancement of health and well-being across the campus community’ (health/well-being professional, USA, male).

Theme four: language syntax and comprehension

This theme reflects respondents’ emphasis on the need for language within the document that is clear, inclusive, and easy to understand across global contexts. Language syntax refers to the structure and organization of sentences, while comprehension relates to how easily readers can understand the Charter’s intent, key concepts, and commitments. Respondents stressed that wording, grammar, and terminology all influence how accessible it is to diverse audiences, including students, employees, and international stakeholders. Clear definitions, consistent phrasing, and culturally inclusive language were seen as essential to ensuring the document communicates its goals effectively.

Grammatical edits required

Participants emphasized the importance of using clear, consistent, and inclusive language throughout the Charter to enhance global accessibility and ensure that key messages are not lost due to jargon or culturally specific terminology. Minor grammatical changes were recommended to improve readability: ‘Use wellbeing (no hyphen), I feel like wellbeing is becoming the more common spelling as opposed to well-being’ (P322, health and well-being professional, location and gender not specified). Other suggestions included capitalizing ‘Indigenous’ (academic/faculty, Canada, female), using the Oxford comma, and pluralizing terms consistently across the document.

Health promotion-related terminology requiring definitions and/or explanations

In addition to grammatical improvements, many participants called for clarification of complex terminology, particularly where health promotion language was seen as vague or undefined. For instance: ‘Optimize human and ecosystem potential, the meaning here is unclear’ (administrator/professional services, UK, female) and ‘They can remain as is, but the terms need to be explained so they are clear distinction between settings and whole systems’ [student (postgraduate), Canada, female].

Clarity required across statements in language, wording, and statement structures

The absence of definitions was seen as a barrier to clarity and broader understanding. To improve the flow and accessibility of the text, respondents also proposed simplifying and restructuring sentence phrasing. As one participant wrote: ‘Prioritize people over the success of our institutions, suggest just an order change’ (administrator/professional service, Canada, female).

Language needs to account for global accessibility

Within this theme, there was also a strong call to ensure the Charter’s language is globally accessible and inclusive of diverse populations and cultural contexts. Participants emphasized the importance of using terminology that resonates across different health systems and is understandable to nonexpert audiences, including students. One participant noted: ‘I like this initiative, but it seems very vague to me. If a student were to read this, I'm not sure if they'd fully understand what is meant here’ (administrator/professional services, health and well-being professional, senior leadership, USA, male).

Discussion

Despite its widespread adoption, the Okanagan Charter has not previously been systematically evaluated or explored in a global context. Researchers in Italy have identified that implementation has been hindered in some regions by uneven uptake, with evidence that while many institutions reference well-being in strategic plans, the integration of health promotion often remains partial or sectoral (Pani et al. 2025). Similarly, studies in African contexts have highlighted barriers related to conceptual clarity, measurement, coordination, and implementation processes that limit the development and evaluation of health-promoting universities (Tafireyi and Grace 2024). In contrast, this study aimed to explore global perspectives and views on the relevance and priorities for advancing the Charter across diverse higher education contexts.

Quantitative findings indicated broad support for retaining core elements, yet substantial proportions recommended revisions across multiple components. Qualitative findings identified four overarching themes: revising to address evolving contexts and concepts, strengthening leadership and governance, enhancing implementation and evaluation, and improving language syntax and comprehension. Collectively, these findings reflect a shared global vision that acknowledges the continued value of the Okanagan Charter and the perceived need for it to evolve in response to emerging global, institutional, and societal changes. Importantly, while respondents articulated common priorities, they also emphasized that implementation feasibility varies considerably across institutional, regional, and sociopolitical contexts. The breadth and depth of these findings also reflect the participatory, cocreative approach of the study, in which stakeholders actively contributed to shaping priorities for the Charter’s renewal, ensuring that revisions are grounded in diverse perspectives and lived experiences.

The need to address the evolving contexts and concepts was a recurrent theme throughout the responses. Since the adoption of the SDGs in 2015, HEIs have been called upon to contribute to global objectives, such as health equity (Goal 3), inclusive education (Goal 4), and the reduction of inequalities (Goal 10) (United Nations 2015). Respondents stressed the need to embed values aligned with the SDGs, such as equity, inclusion, and sustainability, into future iterations into the development of guiding documents, frameworks, or charters to advance the field of health promotion in higher education settings. At the same time, participants acknowledged that regional priorities, resource constraints, and institutional mandates may pose challenges for uniform adoption, reinforcing the need for adaptable rather than prescriptive global guidance. A particularly salient finding was the call for explicit integration of planetary health and climate change. Climate change has been identified as the greatest global health threat of the 21st century (Kanem et al. 2023, World Meteorological Organization 2023). A new document could therefore serve as a unifying mechanism for integrating climate action into the core missions of HEIs advancing both the health of the planet and the campus communities.

Participants highlighted the growing influence of commercial determinants of health, including industries linked to tobacco, alcohol, ultraprocessed foods, and fossil fuels, underscoring the need for guidance that addresses these systemic drivers. The commercial determinants of health have contributed significantly to the global burden of noncommunicable diseases, particularly through the actions of industries producing tobacco, alcohol, ultraprocessed foods, and fossil fuels (WHO 2023). The World Health Organization programme of work on Economic and Commercial Determinants of Health aims to expand on existing related antimisinformation on health-related initiatives within the higher education sector (WHO 2022). Integrating guidance on mitigating commercial determinants into the Charter would ensure that HEIs are equipped to address these influences ethically and strategically, aligning institutional practices with global health promotion objectives.

Findings reaffirmed the critical role of leadership in embedding health promotion within the culture and operations of HEIs. Consistent with previous research (Dooris et al. 2021) (Squires and London 2022), respondents described how progress often depends on sustained commitment from senior leaders who champion well-being as integral to institutional missions. In the Canadian context, leadership was particularly influential in the implementation of the Okanagan Charter, with progress frequently tied to the presence or loss of key champions within governance structures (Squires and London 2022). These findings suggest that future related documents could explicitly delineate leadership accountability mechanisms, clarifying expectations for senior management, academic leaders, and student representatives. Integrating principles of shared governance and distributed leadership could further strengthen institutional ownership and sustainability. Additionally, embedding health promotion into institutional strategy documents, performance indicators, and leadership development programmes could ensure continuity and help embed sustained well-being.

Participants called for practical tools, such as adaptable case studies, templates, and evaluation frameworks, to support implementation and accountability of health-promoting campuses across diverse contexts. Evaluation has been identified as vital for health promotion initiatives as it facilitates feedback on actions (Stock et al. 2010). While some resources do exist, such as the UK Healthy Universities Network Self-Review Toolkit (UK Healthy Universities Network 2012), or the Higher education Authority of Ireland Self-Evaluation tool (Higher Education Authority 2024), their applicability is largely national or regional, and global comparability remains limited. Differences in funding structures, governance models, and multisectoral collaboration pose ongoing challenges (Suárez-Reyes et al. 2019). Respondents emphasized that any global tools should be scalable, enabling institutions at different stages of health-promoting campus development to engage meaningfully without imposing unrealistic expectations.

Given these disparities, a renewed global document presents an opportunity to address these limitations by offering clearer implementation pathways and fostering accountability mechanisms that can be adapted across diverse global contexts. A revised global guidance document could therefore serve as a platform for harmonizing evaluation practices while allowing flexibility for local adaptation; alternatively, this could take the form of an accompanying document providing practical tools and adaptable frameworks to guide implementation and evaluation. By involving stakeholders in the design of these practical tools, the revision process would embody participatory principles, ensuring that guidance is responsive to the needs and experiences of those who will implement it.

Language, syntax, and comprehension were identified as foundational factors influencing the accessibility and practical application of the Okanagan Charter. Participants pointed to grammatical inconsistencies and the presence of technical jargon as barriers to engagement, particularly for nonspecialist audiences and non-English–speaking regions. This theme highlights that effective communication is central to ensuring that a renewed document’s intent translates into action. The World Health Organization’s Strategic Communications Framework for Effective Communications offers a relevant lens through which to view these findings, emphasizing accessibility, actionability, credibility, relevance, timeliness, and clarity (WHO 2017). Since the Charter’s publication, terminology in health promotion has evolved, particularly following the 2021 update of the Health Promotion Glossary (Nutbeam and Muscat 2021), which standardizes key terms across global contexts. The adoption of updated definitions could enhance conceptual clarity and reduce misinterpretation. Input from stakeholders globally in future iterations would assist in identifying barriers to comprehension.

Respondents also noted confusion around interchangeable use of terms, such as health-promoting universities, healthy universities, and whole-systems approaches, echoing prior literature that conceptual ambiguity can dilute policy coherence and hinder implementation (Tafireyi and Grace 2024). Clarifying terminology in future versions of the Charter would strengthen its utility as both a strategic and an operational framework. Furthermore, participants highlighted the dominance of high-income country perspectives in the Charter’s language, underscoring the need for more contextually adaptable wording. As prior research stresses, frameworks designed in high-income contexts must be interpreted and adapted to local realities, especially within the African regions (Tafireyi and Grace 2024). Revising the Charter’s language to reflect global diversity and inclusivity would enhance its cultural resonance and facilitate broader engagement across world regions.

Limitations and future directions

While the survey aimed for global reach, several limitations must be acknowledged. Although it was offered in both English and Spanish to enhance accessibility, some regions and stakeholder groups remained underrepresented, which may affect the generalizability of the findings. The online format may also have excluded participants with limited internet access or lower levels of digital literacy, thereby constraining the diversity of perspectives. Students, despite being the primary beneficiaries of health-promoting campus initiatives and the Okanagan Charter, were underrepresented in the sample. This may have been due to recruitment pathways that primarily reached institutional and professional networks or perhaps that student awareness of the Charter and its aims may be more limited than employees. Future research should therefore prioritize targeted and participatory approaches to student involvement, such as collaboration with student unions, integration into teaching and learning activities, and cocreation methodologies that foreground student lived experience. In addition, a substantial proportion of respondents identified as health and well-being professionals, which may have influenced the emphasis placed on leadership, governance, and evaluation mechanisms. While these perspectives are critical for understanding institutional implementation, they may not fully represent the priorities or experiences of the wider higher education population.

Additionally, as a mixed-methods study, the quantitative components of the survey provided broad descriptive data, while the qualitative responses offered richer contextual insight. This approach prioritized depth of understanding over detecting statistical differences between subgroups, though future research could explore these differences more systematically. Future research could also benefit from interviews or focus groups to capture more detailed contextualized perspectives from a broader range of stakeholders, including underrepresented continents, students, global health organization representatives, and nonhealth and well-being experts. Longitudinal research could also be beneficial in tracking the implementation of the health promotion actions over time in HEI contexts globally.

Conclusion

This study provides the first global examination of stakeholders’ perspectives on the relevance and future direction of the Okanagan Charter within contemporary higher education contexts. Findings indicate that many respondents valued the foundational elements of the Charter, alongside a clear call for its evolution to address contemporary priorities, including planetary health, and the commercial determinants of health. Our findings emphasize the need for clarity and practical utility of a future charter, particularly through improved language, actionable implementation strategies, and evaluation guidance. Our results underscore the importance of using systems-based approaches and accountable leadership and governance structures for embedding health promotion within institutional culture. Collectively, while future research is needed, our findings provide a roadmap for advancing the Health Promoting Campuses movement ensuring that global guidance remains responsive to the diverse and evolving landscapes of higher education landscapes.

Author contributions

Aoife Noonan (Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Visualization, Writing—original draft, Writing—review & editing), Audrey Tierney (Conceptualization, Data curation, Funding acquisition, Methodology, Project administration, Supervision, Visualization, Writing—review & editing), Catherine Norton (Conceptualization, Data curation, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Writing—review & editing), Kathleen McNally (Formal analysis, Investigation, Methodology, Project administration, Resources, Visualization, Writing—review & editing), and Catherine B. Woods (Conceptualization, Data curation, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Writing—review & editing).

Supplementary material

Supplementary material is available at Health Promotion International online.

Supplementary Table S1 International Survey Instrument

Conflicts of interest

None declared.

Funding

This research was supported by the Irish Higher Education Authority and the University of Limerick.

Data availability

The data underlying this article will be shared on reasonable request to the corresponding author.