Generating solutions to complex problems requires an in-depth analysis of the different levels of influence. An approach that appreciates the social determinants and multivariable factors is used in a social-ecological framework. When it comes to health, the individual certainly has some power and choice over their health status. However, there are many components outside of personal control when looking at the bigger picture (Cohen et al., 2000). The nomenclature for the different categories or levels of influence vary in the literature, but the framework basically consists of intrapersonal, interpersonal, community, and societal groupings (Canadian Council on Social Determinants of Health, 2015). For my analysis of the opioid crisis, I selected a social-ecological framework that broke down the societal category further, to include a public policy level and organizational level. The argument behind using a social-ecological approach to health problems is that modifying social conditions, political environments, and upstream factors has powerful impacts on health status (Stellefson, 2019). It looks at the problem through a broader lens. Stellefson (2019) states:
"The social-ecological model focuses on individuals and their interactions with larger social systems that influence health outcomes."
Video 1. Social-ecological model overview (Stellefson, 2019).
Applying a social-ecological model to health involves breaking down the influential factors into different categories. These levels are concisely described in Video 1.
Levels of Influence:
(Stellefson, 2019; Canadian Council on Social Determinants of Health, 2015)
1) Individual
Knowledge, attitudes, behaviour, self-efficacy, developmental history, gender, age, religious identity, race, sexual orientation, socioeconomic status, values, goals, expectations, literacy, stigma.
2) Interpersonal
Social networks, support systems, family, friends, peers, coworkers.
3) Organizational
Organizations or institutions with rules and regulations with impacts on individuals or groups.
4) Community
Physical environment, relationships among organizations, institutions, and informational networks.
5) Public policy
Local, provincial, federal, and global law and policies.
Most interventions target downstream factors including individual risk factors or interpersonal processes. A study in the United States that applied a social-ecological approach to 157 health promotion interventions found that only 20% addressed concerns at the community level, such as improvements to parks and recreation facilities (Stellefson, 2019). Even fewer articles considered the public policy level, with only 6% of articles mentioning changes to public policy such as federally or state-mandated interventions (Stellefson, 2019). These upstream factors also need to be considered in the evaluation and development of health education, theory, research, and training (Stellefson, 2019). Video 1 mentions successful application of a social-ecological model to improve media advocacy, policies, and health behaviours such as nutrition and physical activity in school (Stellefson, 2019).
Overall, a social-ecological model takes into account the social determinants of health. Video 2 makes a comparison between hospital admission rates between asthmatic children from low-income and high-income neighbourhoods (Canadian Institute for Health Information, 2018). Although the average rate of admission due to asthma decreased across Canada, the child from the low-income community had repeated hospitalizations whereas the child from the high-income community had never been hospitalized (Canadian Institute for Health Information, 2018). The children had different experiences with the same diagnosis based on where and how they grew up (Canadian Institute for Health Information, 2018). The video illustrates the importance of social supports, healthy child development, physical environments, income and education to the outcome of health (Canadian Institute for Health Information, 2018). Some disparities in health status are avoidable and due to unfair factors (Canadian Institute for Health Information, 2018). The Canadian Institute for Health Information (CIHI) has clearly defined health inequality, healthy inequity, and equity stratifiers; also, CIHI has created a tool kit which can be used to assess strategies and interventions (Canadian Institute for Health Information, 2018). CIHI suggests using their tool kit to formulate a plan, design strategies, analyze data, and report findings (Canadian Institution for Health Information, 2018).
Video 2. Measuring health inequalities (Canadian Institute for Health Information, 2018).
Multilevel analysis examines hierarchical data structures of observations nested within groups (Diez-Roux, 2000). This hierarchical modelling allows for simultaneous examination of predictors at the macro-level of groups and micro-level of individuals (Diez-Roux, 2000). Human behaviour is a reciprocal interaction between individuals and their environments (Cohen et al., 2000). The environment is more than just the physical layout of neighbourhoods; it also refers to the socio-political climate and group norms. Moreover, the products that are accessible within the environment are important when considering alterations to a community. One way to reduce or prevent high-risk behaviour is to improve the conditions of the environment (Cohen et al., 2000). These changes can facilitate or constrain certain behaviours (Cohen et al., 2000).
Factors of the environment: (Cohen et al., 2000)
1) Structural: Availability, accessibility and price of protective versus harmful consumer products.
2) Physical: Physical characteristics of products, tangible objects such as consumer products, buildings, and the physical layout of neighbourhoods.
3) Social: Policies and guidelines to limit high-risk behaviours including law enforcement.
4) Media and cultural messages: Group norms and individuals' beliefs, attitudes, and cognitions.
Let's look at some examples that illustrate the usefulness of social-ecological frameworks that consider the social determinants and environmental factors. The following summaries show how health can be influenced at multilevels.
Climate change has many impacts on our health
(Eco Africa, 2017)
Rising temperatures results in the survival of disease-carrying species in more regions. Higher altitudes and an increasing number of countries, that would have previously been too cold for these animals to sustain life, are now hospitable environments due to global warming. The increasing amount of compatible places for survival encourages the animals to migrate further, making humans potentially susceptible to disease. For example, malaria-carrying mosquitoes can spread the disease with a simple bite. Invasive species of plants are also able to thrive in new regions, disrupting the local ecosystem and potentially irritating those with allergies if they contain a lot of pollen such as the Common Ragweed. This plant, native to North America, can survive in parts of Europe now that the temperatures have increased. Periods of pollen production are longer when it is hotter, another downside for allergy sufferers. The prevalence of extreme weather conditions, such as floods, increases as a result of climate change. Floods are dangerous not only because of risk of drowning but also the spread of epidemics. Climate change impacts everyone, including people in poor communities that cannot afford solutions such as medication or high quality construction for homes in safe areas. This example, Video 3, leaves us with the recommendation to "put the breaks on climate change." (Eco Africa, 2017).
Video 3. Our health and climate change (Eco Africa, 2017)
Social inequality magnifies vulnerability to disaster
(Gahman & Thongs, 2017)
As extreme weather conditions are becoming more prevalent due to climate change, underdeveloped countries are experiencing increased severity and frequency of disasters. In particular, former colonies are struggling due to underdevelopment and weak institutions which results in poorer disaster preparedness and response. Longtime colonial rule has made Caribbean societies and ecosystems vulnerable. This includes physical hazard exposure (how directly it is threatened by disaster) as well as social vulnerability (how resilient it is). People that are struggling to make ends meet do not have enough money left over to prepare for disasters. Food, clean water, shelter, and medicine take precedence over measures that would help in the event of a natural disaster like installing hurricane-resilient roofs. Their homes are of low quality and poor construction, lacking things like storm shutters or solar generators. Moreover, these individuals cannot afford homeowner's insurance that would help with the recovery period. The likelihood of poor people getting hit the hardest by a storm is also in part because they live in disaster-prone areas which are more affordable. This includes unstable deforested hillsides and eroding riverbanks. Also, their environment is often polluted and harmed from companies wanting to extract resources; for instance, ExxonMobil drilling in oil-rich Guyana. Unfortunately, poor families do not have enough resources such first aid kits, or a means to receive disaster warnings via a satellite phone or emergency radio.
Upon review of a massive earthquake in Haiti during 2010, it was found that women were especially at risk. Women's stress response worsened if prior trauma was experienced which was the case for 75% of the displaced women. They had a history of sexual violence which resulted in poorer recovery after the earthquake. Moreover, women are disproportionately exposed to illness following a disaster. This is, in part, explained by rigid gender roles, which requires women to do household labour thereby exposing them to contaminated water supply. Post-disaster water which is used to clean the house may contain sewage, E. coli, salmonella, hepatitis A, yellow fever, or cholera. Furthermore, women have increased psychological stress due to the responsibility of finding food and water during shortages post-disaster. This is another role typically given to women in these countries, despite them generally having less income or credit compared to men.
Marginalized people in former colonies have had a worse experience due to corruption from local governments. For example, land rights violations have dissolved the trust between people and states. Also, contemporary governments have divested public education by reducing the amount of financial aid available for working-class university students or people from low-income communities. In addition, Gahman and Thongs (2017) argue that poverty reduction efforts have been met with international interference. Haiti, which overthrew European enslavers in 1804, was economically stifled by global powers; US military occupation of Haiti from 1915-1934 and policy of intervention have had lasting effects on its governance.
Going forward, improvement efforts need to target multilevels by assessing:
1) Social factors (poverty and gender)
2) Ecological risk (climate change)
3) Democracy (political education)
By using a social-ecological approach, hopefully the daily living conditions of people in these underdeveloped countries will improve, which in turn will improve post-disaster responses.
Genomic differences do not always explain racial disparities
(Galea, 2015)
From 1979 to 2009, there was a 66% decline among men and 67% decline among women for mortality due to coronary heart disease (CHD). However, rates of CHD remains disproportionately high in African Americans compared to other race/gender groupings. Evidence suggested that access to quality care was likely to explain relatively little of the racial differences when it comes to CHD. Some factors are modifiable such as diet, physical activity, and smoking. These changes fall into the Individual level of a social-ecological framework. When examining CHD at the community level, new factors come into play. The neighbourhood and social environment influences health. Studies have found that residences of disadvantaged neighbourhoods have a higher incidence of CHD independent of individual level risk factors. For black women, an inverse relationship between hypertension (a risk factor for CHD) and neighbourhood median housing values exists. Neighbourhood-level social capital is a predictor of CHD mortality. It was found that there were substantial regional differences by race, which suggests higher level determinants of the social-ecological framework are better to explain racial differences in CHD. Table 1 shows the racial differences in CHD mortality rates and geographic areas with highest or lowest rates of CHD.
Table 1. Racial differences in coronary heart disease (CHD) mortality rates and geographic areas with highest or lowest rates of CHD.
Interestingly, CHD mortality was attributable to both poverty a segregation. Segregation was associated positively or negatively with CHD in different counties, suggesting significant varies by neighbourhood. Further examination of the geographical regions revealed walkability of the neighbourhood and air pollution being associated with CHD mortality. Therefore, a multilevel answer is needed to address the racial disparities in CHD as seen in Figure 1. Considerations for targets of study and intervention should include access to quality health care, economic deprivation, and segregation.
Figure 1. Multilevel approach to promoting cardiovascular health in the developing world
Using a social-ecological approach to problem-solving encourages us to consider multiple spheres of influence. Although proximate causes are an important area of study, it is necessary to reveal causal relations at higher levels as well. McMichael (1999) cautions that if epidemiologists focus solely on risk factors at the individual level and ignore wider social-environmental causes, then health promotion programs will remain inefficient and only accessible to those in better-educated, better-resourced stratum of society. McMichael (1999) states, "Effective and equitable social interventions require an understanding of the contextual determinants of health risk distribution within the population." Only focusing on risk factors at the individual level results in overly simplistic answer and makes us a "prisoner of the proximate." (Galea, 2015; McMichael, 1999). A preoccupation with proximate factors is a constraint that limits engagement of issues (McMichael, 1999). Social-ecological frameworks are advantageous for public health research because it looks at the broader societal factors that are influencing health outcomes across the life course (Canadian Council on Social Determinants of Health, 2015). Multilevel analysis is useful for informing policy and decision making (Canadian Council on Social Determinants of Health, 2015). It can help identify priority issues and guide inter-sectoral action (Canadian Council on Social Determinants of Health, 2015). A social-ecological approach helps identify opportunities for engagement, collaboration, and partnerships to have the greatest impact (Canadian Council on Social Determinants of Health, 2015).
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Eco Africa. (2017, May 1). Info-film: Our health and climate change. [Video]. DW.
Gahman, L. & Thongs, G. (2017, September 20). In the Caribbean, colonialism and inequality
mean hurricanes hit harder. The Conversation. https://theconversation.com/in-the-caribbean-
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