Social Ecological Model of Health
For many years now, how to define health has been researched and debated. Many definitions have been suggested as the population changes, however, the WHO definition still remains the widely accepted definition. WHO (1948) defines health as” a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” In keeping with this definition many models of how a person can achieve optimal health have been developed. In an editorial by Early (2016), she states, “Decades of research have shown us that the health challenges people face largely influenced by a wide range of factors which are social, cultural, environmental, economic and political.” These have been defined as the social determinants of health and research has shown that these need to be viewed at multiple levels that are overlapping. Why then is health care and treatment of illness still the main focus of many health care systems? It is time to look for a better model to apply to solving how we can make people healthier.
One such multilevel model is known as the Social Ecological Model (SEM). This model is a model of health promotion and prevention. Using a resource from Unicef (2014), “SEM is a theory-based framework for understanding the multifaceted and interactive effects of personal and environmental factors that determine behaviors, and for identifying behavioral and organizational leverage points and intermediaries for health promotion within organizations.” There are five nested, hierarchical levels of the SEM: Individual, interpersonal, community, organizational, and policy/enabling environment as shown below in Figure 1.
Figure 1: SEM Model
Adapted from the Centers for Disease Control and Prevention (CDC), The Social Ecological Model: A Framework for Prevention, http://www.cdc.gov/violenceprevention/overview/social-ecologicalmodel.html (retrieved April 21, 2014).
Looking at the sphere of influence in Figure 1, the importance of how each level/ circle interplays with one another and how health must be addressed on a broader level is displayed. Each of the social determinants of health is recognized in the model and their importance is apparent. A decision a one level of influence can directly impact the result of another level.
A description of each of the levels is found below (UNICEF, 2014):
Individual
Characteristics of an individual that influence behavior change, including knowledge, attitudes, behavior, self-efficacy, developmental history, gender, age, religious identity, racial/ethnic identity, sexual orientation, economic status, financial resources, values, goals, expectations, literacy, stigma, and others.
Interpersonal
Formal (and informal) social networks and social support systems that can influence individual behaviors, including family, friends, peers, co-workers, religious networks, customs or traditions.
Community
Relationships among organizations, institutions, and informational networks within defined boundaries, including the built environment (e.g., parks), village associations, community leaders, businesses, and transportation.
Organizational
Organizations or social institutions with rules and regulations for operations that affect how, or how well
Policy/Enabling Environment
Local, state, national and global laws and policies, including policies regarding the allocation of resources for maternal, newborn, and child health and access to healthcare services, restrictive policies (e.g., high fees or taxes for health services), or lack of policies that require childhood immunizations.
Using the published example of H1N1 vaccine uptake by Kumar et al. (2012), how the model is applied can be explored. Some individual factors were perceived risk and complications post vaccine. Interpersonal were social network influence and positive reactions from those that received the vaccine. Community variables include perceived presence of the disease in the community determined by employee sick time and crowded hospitals. Organizational factors include how much information is directly coming from health care providers. The policy level includes cost associated with the vaccine as well as if you were in one of the identified priority groups. Overall they concluded that variables at all levels of the SEM have an impact. They results from the survey data showed that the decision to get the vaccine at an individual level was influenced by factors at all the other levels and this should be considered if wanting to increase vaccine uptake of a population.
The question remains how best we manage each of the determinants of health when applying it to a broad goal as improving population health. It will take a new framework like SEM and a change in thinking and in practice. It is time for different levels of the government to stop working in silos and start collaborating. Our health is what will benefit.
This video gives an overview of the model:
References
Centers for Disease Control and Prevention (CDC), The Social Ecological Model: A Framework for Prevention, http://www.cdc.gov/violenceprevention/overview/social-ecologicalmodel.html
Early, J. (2016) Health is more than Healthcare: IT’s Time for a Social ecological Approach. Journal of Nursing and Health Studies, Volume 1 Retrieved From: http://www.imedpub.com/articles/health-is-more-than-healthcare-its-time-for-a-social-ecological-approach.pdf
Kumar, S., Quinn, S. C., Kim, K. H., Musa, D., Hilyard, K. M., & Freimuth, V. S. (2012). The Social Ecological Model as a Framework for Determinants of 2009 H1N1 Influenza Vaccine Uptake in the US. Health Education & Behavior : The Official Publication of the Society for Public Health Education, 39(2), 229–243. http://doi.org/10.1177/1090198111415105
UNICEF (n/a) MODULE 1: What are the Social Ecological Model (SEM), Communication for Development (C4D)? Retrieved from: https://www.unicef.org/cbsc/files/Module_1_SEM-C4D.docx
World Health Organization (2018). Constitution of WHO: principles. Retrieved from http://www.who.int/about/mission/en/