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Population Health for Nurses

10.3 Core Principles of the Socio-Ecological Model

Population Health for Nurses10.3 Core Principles of the Socio-Ecological Model

Learning Outcomes

By the end of this section, you should be able to:

  • 10.3.1 Identify the core principles of socio-ecological models.
  • 10.3.2 Describe how socio-ecological models serve as a framework to understand how behaviors both affect and are affected by various contexts.
  • 10.3.3 Discuss health behavior using the components of a theory or model.

The Socio-Ecological Model (SEM) is a classic theory of child development that scholars and clinicians from different disciplines have adapted over time to fit the phenomena of other fields. Its core principles encourage the view of individuals as existing within many relationships and contexts. A consistent idea among similar models is that multiple factors can influence health, and clinicians, educators, researchers, and policymakers must take a broad approach to thinking about health and the many shaping factors. Using the SEM as well as theories facilitating an exploration of the nested, interdependent, intersectional, dynamic interactions of individuals and their surroundings in today’s complex world will help nurses meaningfully understand and address health problems. The Socio-Ecological Model offers a way to study and organize how personal, situational, community, societal, political, and other contexts influence health behaviors and outcomes. Nurses and nursing students can guide their professional practices with this model to support thorough assessments of client health and targeted, realistic care planning, among other benefits. While SEMs can help structure the research, work, planning, and implementation processes of nurses in community/public health, remember that SEMs may not include all contextual factors that are important to a particular community or specific health problem. Further, not all findings from work guided by SEMs will apply to individuals within a population or community.

The current version of the model has evolved from many interprofessional theories and studies of health and behavior that started in the 1970s with psychologist Urie Bronfenbrenner, who called for researchers to consider how human growth and behavior can both accommodate and change based on environments and systems and how people interact with them (Bronfenbrenner, 1977). Bronfenbrenner originally developed this model to describe child development and identified four systems nested around the individual child that impact development: microsystem, mesosystem, exosystem, and macrosystem. Years later, Bronfenbrenner added chronosystems as an additional context imperative to consider in analyzing child development (Bronfenbrenner, 1986). Table 10.2 presents definitions of each system.

System Definition
Microsystem Complex relations between the developing individual and environment and the immediate setting of the individual. The setting is a place with particular features in which the individual engages in particular activities in particular roles—for example, their home (a child), school (a student), or workplace (an employee).
Mesosystem The interrelations among major settings containing the developing individual at a particular point in their life—for example, interactions among family, school, and peer groups.
Exosystem An extension of the mesosystem that includes other specific informal and formal social structures that do not contain the individual but do encompass the settings where the individual is found—for example, major institutions of society, the neighborhood, mass media, government agencies, and social networks.
Macrosystem Institutional patterns of the culture and subculture. Macrosystems direct norms and activities. A macrosystem may include codified laws, regulations, and rules but can also include informal and implicit norms. For example, the economic, social, educational, and legal systems shape the meaning and motivation of how individuals are treated and interact with each other in different settings.
Chronosystem The influence of time on an individual’s development, including life transitions and events over the course of life.
Table 10.2 Systems of Bronfenbrenner’s Socio-Ecological Model (See Bronfenbrenner, 1977; 1986; 1995.)

UNICEF Socio-Ecological Model

Specific to population health, the United Nations Children’s Fund (UNICEF) uses a SEM as a conceptual framework for many health-promoting initiatives (Baudot, 2015). The model facilitates an analysis of barriers and benefits to health. For example, researchers have used the model to study and improve health in complex settings related to organization priorities, including childhood immunization in Nigeria, nutrition in the Marshall Islands, suicidal ideation in China, and the relation of poverty, the environment, and menstrual health management in India (Angeli et al., 2022; Kodish et al., 2022; Olaniyan et al., 2021; Zhou et al., 2022). Levels of the UNICEF model include individual, interpersonal, community, organizational/institutional, and policy/systems (also known as enabling environments). UNICEF also specifies methods or actions to take to effect change at each level. Table 10.3 provides definitions of the levels and actions for health change.

Level Definition Method for Change
Individual/Interpersonal Knowledge, attitudes, and practices among a person (individual) and families, friends, and social networks (interpersonal) that affect decisions and actions Advocacy
Social mobilization
Community Social beliefs and norms, economic conditions, community resources, knowledge, and attitudes about an issue among community members, and the sense of empowerment and efficacy in a community that impacts choices, decisions, and practices Behavior change communication and social change communication
Organizational/Institutional Conditions of a system (e.g., educational system, health care system) that affect inclusion and quality, such as specific institution policies, guidelines, access, geographical proximity, physical infrastructure, resource management, capacity, and safety Social mobilization
Policy/System Enabling Environments Policies and governance that either facilitate or discourage inclusivity and quality Advocacy
Table 10.3 UNICEF Socio-Ecological Model Levels and Methods for Change (See Baudot, 2015.)

CDC Social-Ecological Model

The CDC has also used a social-ecological model (also SEM) for violence prevention to help community health clinicians and other workers in the field of violence prevention better understand the factors that influence violence, place people at risk of violence, and protect people from perpetrating or experiencing violence (CDC, 2022). The CDC model has four levels: individual, relationship, community, and societal. Table 10.4 defines the levels of the model and includes proposed prevention strategies to address violence at each level.

Level Definition Prevention
Individual Factors of an individual’s biological or personal history that increase the likelihood of experiencing violence or becoming a perpetrator. For example, age, education, income, substance use, and history of abuse may correlate with violence. Promote violence-prevention attitudes, beliefs, and behaviors (e.g., healthy relationship skill programs and conflict resolution training).
Relationship Close relationships, meaning those with social peers, partners, and family members, influence an individual’s behavior and can contribute to the violence experience. Prevention and mentoring programs for parents and families that strengthen parent-child communication and promote healthy relationships.
Community Schools, workplaces, and neighborhoods in which social relationships occur. Some communities have characteristics that are associated with becoming victims or perpetrators of violence. Improving the physical and social environment across community settings and addressing other conditions, such as poverty and alcohol access, that support violence in communities.
Societal Broad societal factors that either encourage or inhibit violence. Social and cultural norms and health, economic, educational, and social policies that maintain inequalities between groups may promote violence. Promote societal norms that are protective against violence, and bolster household economic security, opportunities for education and employment, and policies that affect structural determinants of health. Figure 10.5 shows an example of change at the societal level.
Table 10.4 CDC Social-Ecological Model Levels and Prevention Strategies (See CDC, 2022.)
Five legislative measures included in the Bipartisan Safer Communities Act of 2022 are: Enhanced review process: gun buyers under the age of 21 years must undergo a background check of juvenile and mental health records; Closes the boyfriend loophole: dating partners, as well as spouses and ex-spouses, convicted of domestic abuse may not purchase guns; Provides federal aid for red flag laws: funds support removal of guns from owners for whom there is concern of harm to themselves or others; Stronger federal penalties for illegal purchases: those purchasing guns illegally may face a prison sentence of 15 years; and Mental health support: expansion of school-based health care services and crisis recognition and intervention.
Figure 10.5 Access to a weapon can significantly increase the harm caused by violent incidents. Legislative measures included in the 2022 Bipartisan Safer Communities Act can mitigate the occurrence and impact of violence in communities. This bill represents the most significant federal legislation to address gun violence in nearly 30 years. (See National Institute for Health Care Management, 2023; attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Healthy People 2030

Reduce Firearm-Related Deaths

Firearm-related injuries and deaths are a major health issue in the United States, and the problem is worsening. In 2018, there were 11.9 firearm-related deaths per 100,000 people in the United States, and by 2021 that number had increased to 14.6. The United States averages almost two mass shootings per day in which four or more people are killed or injured. Deaths and injuries following homicides, suicides, unintentional injuries, and mass shootings are both tragic and preventable with comprehensive policy and community-focused approaches. Generating such solutions remains elusive and contentious and must start with acknowledgement of gun violence as a public health problem. For more information on ending gun violence, visit the Everytown for Gun Safety site.

(See ODPHP, n.d.-b; O’Rourke, 2023.)

Theory in Action

The Social-Ecological Model, Health Promotion, and Gun Violence

In this video, Mighty Fine of the American Public Health Association shares information about deaths and injuries secondary to gun violence. He notes that homicides, unintentional shootings, assaults, suicides, and mass shootings are events that contribute to gun violence being a major public health problem in the United States.

Watch the video, and then complete the following exercise.

Categorize each of the interventions that Fine discusses based on the level of prevention and the level of the CDC Social-Ecological Model.

Levels of prevention include:

  • primordial,
  • primary,
  • secondary,
  • tertiary, and
  • quaternary.

The CDC Social-Ecological Model levels include:

  • individual,
  • relationship,
  • community, and
  • societal.

Models in Research and Practice

Using models and frameworks is not just for major organizations. Nurses and care teams can demonstrate, assess, evaluate, and plan for the complex and interacting nature of individual, community, and system factors through the use of models and frameworks. Nurses can impact change across levels by using these models and frameworks and considering the many factors that can impact the development of health problems and the success in or failure to adequately address problems. Client behaviors can affect their health, institution, community decisions, and larger system policies. Occurring concurrently, institutions, communities, policies, and social factors affect client health and behavior. Research teams also use these models to direct studies and organize data so meaningful clinical change can result. This section will explore several recent population health projects that were guided by the SEMs.

Health literacy measures how well clients can find, understand, and use information and services to make informed health decisions for themselves or others. When health literacy is poor, clients may not engage in health care services, may lack sufficient access to care, and may not employ health-promoting behaviors. Researchers used the SEM to guide a study of factors at the interpersonal and organizational levels that impact health literacy among clients seeking care at a federally qualified community health center (FQHC) (Greaney et al., 2020). FQHCs are clinics providing primary care services to all clients regardless of their ability to pay (Centers for Medicare and Medicaid Services, 2017). Ensuring that the clinicians of FQHCs are prepared to address and improve health literacy is important in helping clients access their care and improve their health. As the SEM posits that individual behaviors are influenced by intrapersonal, interpersonal, organizational, community, and policy-level factors, the researchers determined that exploring the interpersonal and organizational levels via staff interviews was essential to understanding health literacy at these critical centers. Staff participants recognized the impact of health literacy on client and population health outcomes and discussed creating a centralized health information database for clients of varying levels of health literacy. Such a database could include pictures and other visual aids to communicate health information. Training for staff on assessing health literacy among clients was also suggested, representing an organizational-level change that supports interpersonal clinician-client health communication.

Pregnancy in children and adolescents poses significant health risk to both the pregnant person and the infant. Pregnant children and adolescents are at a higher risk of mortality, preterm delivery, and delivering low birth weight babies (World Health Organization [WHO], 2023). In addition to physical health risks, young pregnant people face challenges completing their education and maintaining employment, which have both immediate and long-term implications for the health of the individual and their family. Researchers used the SEM to guide a study of contraceptive service use in the Ebonyi State of Nigeria, given the model’s ability to help describe the multiple layers and influences of environmental, social, and community factors that influence health behavior (Ezenwaka et al., 2020). Table 10.5 provides a listing of factors impacting contraceptive access at each SEM level related to this study. The research team determined that many barriers to accessing contraception existed across the SEM levels for youth in the Ebonyi State, and most were not within the control of children or adolescents. Strategic involvement of community partners, clinicians, and community adults would be essential in promoting contraceptive service use among children and adolescents.

SEM Level Factors
Individual Poor awareness and knowledge of contraception
Fear and experience of side effects
Cost of services
Lack of confidence/low self-esteem related to seeking contraception
Interpersonal Poor parental communication of sexual health matters
Community (cultural, societal, religious) Gendered cultural norms
Cultural and religious norms
Societal shaming
Misconceptions about contraceptive use
Organizational Unfriendly/judgmental providers
Lack of privacy and confidentiality
Poor support for youth-friendly health centers
Societal Peer and media influence
Restricted sexuality education
Lack of social and community support
Poverty level
Table 10.5 Factors Affecting Contraceptive Service Use among Adolescents by SEM level

Beyond the challenge of developing a vaccine for COVID-19, clinicians and scientists faced obstacles in addressing vaccine hesitancy among the global population during the pandemic. Researchers conducted an online survey of 592 adults in the United States to examine intentions to obtain a COVID-19 vaccine, using the SEM to determine relations between vaccine intentions and the intrapersonal, interpersonal, institutional, and community-level factors (Latkin et al., 2021). Intrapersonal factors of the respondents who felt negative or ambivalent about becoming vaccinated against COVID-19 included Black race, lower educational attainment, conservative political ideology, no influenza vaccination in the last year, skepticism about COVID-19, and lower engagement in preventative behaviors. Lower levels of perceived social norms (i.e., social rules or typical behaviors and actions) and preventative behaviors were interpersonal factors contributing to negative or ambivalent intention to become vaccinated. Institutional factors such as lower trust in national health agencies also contributed to negative or ambivalent feelings. At the community level, lower perceived likelihood of becoming ill with COVID-19 was associated with negative vaccine intentions. At the time of vaccine development through today, studies that evaluate vaccine hesitance in the context of all SEM levels are important to developing targeted interventions. Targeted interventions are important to supporting vaccine uptake among a sufficient enough percentage of the global population to avoid acquisition, recurrence, or resurgence of vaccine-preventable illnesses such as COVID-19.

Intimate partner violence (IPV) is a global health issue affecting people of all genders and across age groups. In Mexico, nearly 44 percent of women have reported experiencing IPV in their lifetime (Willie et al., 2020). Femicide, the intentional murder of women because they are women, is prevalent in Mexico with an estimated seven women killed each day (Meyer, 2017). These circumstances inspired a research team to investigate access to IPV resources among women in Mexico. A research team collected information via a survey of 950 Mexican women who experienced IPV to determine the socioecological factors that influenced their utilization of community-based supports (Willie et al., 2020). The socioecological levels used to organize the study were individual, partner, family, and community. At the individual level, the team determined that women who were separated or divorced from their partner used 70 percent more IPV resources than women in common-law marriages. Women who knew about more community resources accessed more resources. The severity and manner of the violence also mattered: The women surveyed indicated that they were more likely to use community resources when there was a greater risk of lethality, as well as when a family member of the violent partner was encouraging the abuse. Also, at the relationship level, women being likely to disclose IPV to family and friends increased the resources used. In the community, strong norms regarding resource utilization also supported resource access by women experiencing IPV. The study's results can aid researchers and clinicians in developing targeted interventions to promote IPV services available at community sites, such as emergency medical services, counseling, and hotlines. Additionally, these findings can support the creation of community-wide outreach efforts to strengthen social norms around utilizing support and interventions for IPV.

Theory in Action

Socio- and Social-Ecological Models

Visit the CDC website page about the socio-ecological model, view the UNICEF report online, or review this video Health Belief and Transtheoretical Models—Fundamentals of Nursing to see how SEMs can be depicted via illustration. Select a model that you would like to use to conduct a practice application, and then sketch the model on a piece of paper.

Think back to Mo from the chapter opening scenario, and then complete the following exercise.

  1. Pick one of Mo’s health problems or a condition he may be at risk for (the health problem may be acute, chronic, self-limiting, or requiring treatment and may be individual or a risk for his family/community).
  2. Fill in each level of your sketched model with information from his scenario.
  3. Add information to each level that you know about barriers and facilitators to health from your other foundational nursing courses.
  4. Identify at least one nursing action at each level of the model that can contribute to ameliorating Mo’s health problem and to helping clients in the future that may have similar health problems.

The chapter began with a reminder that clients do not exist in isolation and emphasized the interdependence of clients and the environment. Multilayered external influences impact a client’s symptoms, health conditions, access to care, quality of care, and opportunities for improved health. Nurses can identify and address the intrapersonal, interpersonal, community, organizational, policy, behavior, genetic, environmental, and social factors that influence the health and well-being of people and populations.

By using SEMs and theories of health behavior, nurses can comprehensively organize and address health. While SEMs are not a replacement for individual-level assessment and intervention in health care, the SEM recognizes the complexity of health status, health promotion, risk reduction, and disease prevention given the interplay between clients and their own situations and environments. SEMs help provide a comprehensive perspective of population health problems and offer insights into solutions across levels. By considering individual, interpersonal, community, and societal factors, the SEMs allow for a more holistic understanding of health problems that can arise from multiple sources. SEMs also acknowledge that individual behavior or choice is not solely responsible for the health outcomes of a particular client or the larger population, collectively. Instead, SEMs emphasize the importance of broader contextual factors and encourage clinicians and researchers to intervene at multiple levels to create sustainable and meaningful health change.


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