Remember your imaginary pet, Goldie the goldfish from the resource paper entitled, “Improving Health: It’s All About the Ecosystem.” Just in case you did not read that document, let me provide a summary for you.
You have a pet goldfish named Goldie. You care about Goldie; want her to be healthy; and want her to live a good, long life. What would be the best way to ensure that she experiences positive health and quality of life?
The most important determinant of health for Goldie is the quality of the water in which she lives – her ecosystem.
Goldie’s health is influenced MOST by her ecosystem – herbiome – the environment in which she lives. Her ecosystem includes every living organism and non-living thing. It embodies every single aspect of her habitat, including all the interactions between and among the different elements.
Just like Goldie, human beings also live in an ecosystem that includes our physical and social environments. Our ecosystem also includes every living organism, every non-living thing, and all the interactions between and among the different elements.
Every person reading this is “swimming” in an ecosystem that either supports and facilitates positive health or negative health. These “ecosystem-type” determinants of health (i.e., the causes of the causes of health) are FAR more powerful and impactful than any other variable including knowledge, beliefs, perceptions, attitudes, behaviors, access to medical care, or the quality of health services.
The odds of people experiencing positive health and quality of life are greatly increased when multiple factors within their ecosystem support positive health.
If you desire to truly make a difference in the lives of others, you must design interventions that positively influence multiple factors in the ecosystem.
The Socio-Ecological Model
One model that the 1795 Group uses as a planning model is the Socio-Ecological Model (McLeroy, Bibeau, Steckler, and Glanz, 1988). This model posits that health is determined by influences at multiple levels of human ecology.
This model suggests that human health is influenced by a complex web of influential factors in the physical and social conditions in which we live, learn, play, recreate, and work. These factors are all interrelated. A change in one causes a ripple effect of changes in other factors – just like a domino effect.
Five Levels of Inter-Related Ecological Influence
This model teaches us that both population-level (upstream) and individual-level determinants (downstream) of health are important. The higher we go on the rungs of the model, the greater the odds that we will have more positive impact. Why? Because the higher we go, the more levels of the ecosystem that we influence.
Because significant and dynamic interrelationships exist among these five different levels of health determinants, interventions are most likely to be effective when they address determinants of health at all levels. Put simply, the best programs include as many of these five levels as possible. See below for a brief description of each level.
Level # 1 – INTRA-Personal/Individual Factors: This is the lowest level of the model. Focusing here will yield the lowest level of impact. However, many programs of the past have focused here? Why? Because many physicians and public health specialists think like this: If we can only change the thoughts, beliefs, and attitudes of the person, their behavior will also change. This is not necessarily true.These INTRA-personal factors are mostly “between the ears” of the person – inside their heads (e.g., knowledge, beliefs, attitudes, perceptions, behavior, self-concept, and skills). However, these factors may also include the person’s developmental history, gender, religious identity, racial/ethnic identity, sexual orientation, economic status, financial resources, values, goals, expectations, age, genetics, resiliency, coping skills, time management skills, health literacy ability to access health care services and, perceptions of stigma of accessing mental health services.
Level # 2 – INTER-Personal Factors: Our decisions and actions are certainly influenced by those around us – especially those who are significant or influential to us. INTER-personal factors are those that occur AMONG people and groups, including formal and informal social networks and social support systems, including family, work group, and friendship networks.
Level # 3 – Organizational/Institutional Factors: The institutions of school, work, where we worship, recreate, and receive health care influence us. These factors include both formal and informal rules, policies, procedures, and regulations. For example, for college students these factors would include the campus social climate, class schedules, health insurance policies, financial policies, the lighting, unclean environments, distance to classes and buildings, noise, availability of study spaces, libraries, and common lounge spaces, air quality, and safety.
Level # 4 – Community Factors: Notice that as we continue to move upwards, we move more upstream into the areas that have the greatest impact on health and quality of life. Community factors would include relationships among organizations, institutions, and informational networks within defined boundaries. Examples would include employment, housing, neighborhoods, quality of schools, the walkability of neighborhoods, bike trails, parks, green space, availability of fresh fruits and vegetables, community norms, medical care, geographic location, the built environment, neighborhood associations, safety of neighborhoods, political power and leverage, and transportation.
Level # 5 – Public Policy: This is the highest level of impact and typically includes legislation/laws. Why are such laws so effective? Because they remove human choice from the equation and rely on enforcement (e.g., seat belt laws, texting while driving, auto safety requirements, food safety laws, and clean air legislation). These can include laws and policies at the local, state, national, and global levels. It is easy to see how legislation impacts health both positively and negatively, especially in areas such as the economy and environmental health.
A Major Caveat
The Ecological Model does not have any constructs. As a result, it is not measurable. Therefore, we never use it as our only theory or model for program design. The Ecological Model is simply a planning tool – a way of thinking about and planning a program so that the program’s activities hit as many levels of ecological influence as possible. Your goal is to use as many levels of ecological influence as possible in your program. If money and time are unlimited, the ideal program would touch on all ecological levels.
Selecting a Theory or Model as a Framework for Your Program
Why do programs based on a theory or model have a greater chance of succeeding? How does a good program planner and evaluator select the best theory or model to serve as the framework for program design? You will find these answers in the 1795 Group Resource Paper entitled, “The Importance of Using Theories and Models.”