Social-Ecological Approaches to Health and Risk Messaging
Summary and Keywords
Before health and risk messaging can have the best possible effect, there needs to be an understanding of what might influence health and associated risky behaviors. A wide range of elements needs to be considered, given the many possible influences on health habits and risky exposures. Since “ecology” is defined as the relationship between organisms and their environments, ecological models enable this consideration to be made. As a result ecological approaches have been widely used in health behavior, health planning, and health education.
Ecological theory, with a communication focus, has also been developed, emerging specifically from the field of “information behavior.” Grounded in the work of Bronfenbrenner, on the experimental ecology of human development, the theory grew out of a study of older adults’ information and communication needs and uses, undertaken in the 1990s. The ecological model, as developed, enabled a wide range of personal and social influences on information seeking and communication to be explored with people aged 60 and older. Analysis of the impact of multilevel factors is facilitated by an ecological approach, increasing its value for the task of designing the content of health and risk messages. The “how” of designing health messaging is not addressed specifically by this approach.
Following the study of older adults, the ecological model was broadened, modified, and applied to the study of the information and communication behavior of different community groups, involving a range of topics. The flexibility of the approach is a key strength. A study of information seeking, by women with breast cancer, indicated that several “ecological” elements, such as age, ethnicity, and stage of disease, played a part in the type of information sought and in preferences for how information was communicated. Health and risk avoidance implications emerged from a study of information seeking for online investment, providing another good example of the ways in which the model can be adapted. A range of ecological factors were shown to influence investing behavior, including level of risk taking. A study of people in the Fourth Age (the last stage of life) resulted in a further refined and extended model, as well as making a contribution to the already substantial body of accumulated gerontological knowledge.
There is a wide range of possible influences on health habits and associated risky behaviors. As Gochman (1997) specifies, health behavior is affected by personal, family, social, institutional and community, and cultural factors. For example, health behavior may be affected by the attitudes of family and friends who may not take seriously the need for healthy eating, for example; by ethnicity, which may have an impact on diet and other lifestyle choices; or by people’s education levels and other socioeconomic factors such as whether they are employed and enjoy an adequate income, which enables them to make the best food choices, for example, or have a gym membership. Since “ecology” is defined as the relationship between organisms and their environments, ecological models enable consideration of multiple factors to be made and modeled. Thus they are useful for assisting content development, though not specifically the “how,” of health and risk messaging. Social-ecological approaches have been widely used in health behavior, health planning, and health education.
Ecological theory, with an information and communication focus, has also been developed. Grounded in the work of Bronfenbrenner (1979), on the experimental ecology of human development, the theory grew out of a study of older adults’ information and communication needs and uses, undertaken in the 1990s (Williamson, 1995, 1997, 1998). The mixed methods approach, used for the study, provided extensive data about a wide range of personal and social influences on information seeking and communication. While an ecological framework can be developed from either quantitative or qualitative research, the combination is powerful in providing broad information about a sample as well as enabling “drilling down” to provide in-depth, rich insights which may be surprisingly revealing.
The use of an ecological model, used for the study of older adults, clearly emphasized and displayed those influences on the study participants, who were aged 60 and over. Further details and some of the findings from this study are provided in the section headed “Application to Information and Communication Studies.”
The Influence of Bronfenbrenner
Bronfenbrenner (1979), a Russian-born American developmental psychologist, is best known for his ecological systems of child development. His ecological theory has been applied to other fields, particularly to health behavior and health education (Buchanan, 1997). From an early age, Bronfenbrenner was interested in “the functional interdependence between living organisms and their surroundings” (Bronfenbrenner, 1979, p. xii). His conception of the ecological environment is “as a set of nested structures, each inside the next, like a set of Russian dolls” (p. 3). He referred to these structures as “systems” where the emphasis is on interconnectedness. At the innermost level is the immediate setting, in Bronfenbrenner’s case that of the developing person; for example, the family, the school. He labeled the interrelationships within this setting; for example, between grandparents, parents, and the child, as the microsystem. The interconnectedness continues to the next two layers. The first, the mesosystem, consists of related microsystems, where young people actually participate as they develop; for example, the school, the neighborhood. The second, the exosystem, consists of settings in which young people may never directly interact; for example, the parents’ place of work. Nevertheless, events in those settings may affect what happens in the immediate environment. Overarching all these systems are “patterns of ideology and organization of the social institutions common to a particular culture or subculture.” These are the macrosystems (p. 8).
For Bronfenbrenner there was mutual accommodation between the person and the environment, with each affecting the other. It was an interaction which he viewed as “two directional, that is characterized by reciprocity” (p. 22). The ecological environment which emerges is “a nested arrangement of concentric structures, each contained within the next” (p. 22), the structures being the micro-, meso-, exo-, and macrosytems. With reference to “macrosystems,” Bronfenbrenner considered not only differences in how the lower-order systems (micro-, meso-, and exo-) interact from one country to another, but also patterns of differentiation within a society. For example environments are not necessarily experienced in the same way by the rich and the poor:
The systems blueprints differ for various socioeconomic, ethnic, religious, and other subcultural groups, reflecting contrasting belief systems and lifestyles, which in turn help to perpetuate the ecological environments specific to each group.
(Bronfenbrenner, 1979, p. 26)
Bronfenbrenner was influenced by phenomenologists, such as Edmund Husserl, to the extent that he placed strong emphasis on the experience of participants in an environment. He postulated that “the scientifically relevant features of any environment include not only its objective properties but also the way in which these properties are perceived by persons in that environment” (Bronfenbrenner, 1979, p. 22). His theory was most influenced by the ideas of Kurt Lewin (1935), who took the position that the most relevant reality is not “objective” but that which exists in the mind of the person. Lewin focused “on the way in which the environment is perceived by the human beings who interact within and with it” (Bronfenbrenner, 1979, p. 23). Thus both Lewin and Bronfenbrenner emphasized people’s perceptions of their environments.
Social-Ecological Approaches in the Health Field
Green and Kreuter (2005) examined trends regarding the most commonly used health and behavior theories and models. They used four different date spans, from 1986 to 2005. Of the 13 theories and models that were identified, social/ecological models emerged as among the “most commonly used” only in the last two periods examined, i.e., from 1999 to 2005. As Glanz and Oldenburg (1997) predicted, “both practice and research will gradually evolve towards the multi-level model over time” (p. 151). The ecological model is one example of a multilevel model. McLeroy, Bibeau, Steckler, and Glanz (1988) described the ecological model for health in terms similar to those used by Bronfenbrenner (1979)—with “variables located on different levels (or systems), corresponding to different levels of analysis” (Buchanan, 1997, p. 176). For health behavior and health education, levels of influence include “intrapersonal (biological, psychological), interpersonal (social, cultural), organizational, community, physical environmental, and policy” (Sallis, Owen, & Fisher, 2008, p. 466).
Ecological models of health behavior emphasize the environmental and policy contexts of behavior, while incorporating social and psychological influences. Ecological models lead to the explicit consideration of multiple levels of influence, thereby guiding the development of more comprehensive interventions.
(Sallis et al., 2008, p. 465)
The interaction of influences on behaviors, and of interventions, across the different levels is important. An example of a simple and effective ecological model, which illustrates analysis according to multiple levels, emerged from the diabetes initiative of the Robert Wood Johnson Foundation. The goal was a national program, focused on “improving self-management supports for adults with diabetes in real world clinic and community settings.” The model includes a small circle surrounded by three ellipses, labeled from innermost circle to outermost ellipse: Individual: biological, psychological; Family, friends, small group; System, group culture; Community & policy (Ecological approaches . . ., 2006). Interventions are shown to take place across levels. For example, decisions about resources, made at the community and systems level, influence availability of resources at the individual levels.
Ecological models do not, however, always use standardized labels for levels in health behavior and health education. An example is Sallis, Cervero, Ascher, Henderson, Kraft, and Kerr (2006), who were interested in understanding influences on physical activity. This field had recognized the importance of environmental influences for some time, resulting in researchers in the field being attracted to ecological models (Sallis et al., 2008). Sallis et al. (2006) “synthesized findings and concepts from the fields of health, behavioural science, transportation and city planning, policy studies and economics, and leisure sciences,” to create what they described as a layered or “onion” structure with multiple levels of influence (Sallis et al., 2008, p. 471). The “Ecological Model of Four Domains of Active Living” (Sallis et al., 2006) is extremely complex. There are five ellipses labeled as follows: intrapersonal; perceived environment; behavior: active living domains; behavior settings: access and characteristics; and policy environment. An immense amount of detail is provided especially for “behavior settings” and “policy environment” to a less extent. Three specific types of environment appear at the bottom, beyond the ellipses: information environment, social cultural environment, natural environment.
Thus, the Sallis et al. (2006) model indicates that ecological models do not necessarily conform to particular patterns and labels. The flexibility, as demonstrated with the following information/communication models, is a key strength. Influences on behavior vary significantly according to the topics and/or cohorts studied.
Application to Information and Communication Studies
Williamson’s (1998) ecological model emerged from her PhD research (Williamson, 1995) which focused on the information and communication needs and uses of older adults. The study explored the information-seeking and communication behavior of a sample of 202 older adults, aged 60 and over, living either in metropolitan Melbourne or in rural Victoria, in Australia, in the early 1990s. The sample was made up of 146 persons who were aged 60–74 (identified as young-aged), 44 persons aged 75–84 (called old-old), and 12 individuals aged 85 and older (the very old). Through a range of community groups, extensive efforts were made to select participants who would be diverse in relation to such variables as sex, age, place of residence, education, occupation, income, and country of birth.
A major source of data was a long interview which explored information needs and sources of information used to meet those needs. A particular focus was to understand the extent to which participants sought information purposefully (i.e., they knew what information they needed and set out to find it), as well as the role played by incidentally or serendipitously acquired information, which participants might not have known even existed prior to encountering it. Up to this point, research on information-seeking behavior had focused on purposeful approaches; yet the researcher’s intuition, as well as occasional mentions in the literature (e.g., Wilson, 1977) suggested that people at times obtain information without setting out to find it. Wilson observed that everyone has a “set of habits or routines for keeping his internal model up to date” (p. 36). This involves monitoring the environment by personal observations, discussions with friends, relatives, and colleagues and by use of the mass media. Such routines may or may not have the gathering of information as their goal. In the latter case, information acquisition is often an “incidental concomitant.” While the difference between purposeful information seeking and incidental or serendipitous information acquisition is not easy to explain, most of Williamson’s (1995, 1998) participants seemed to be able to grasp the differences because of the time and effort that were expended in helping them grapple with these concepts.
Eighteen information needs, or topics of concern, were identified in the Williamson (1995, 1998) study. Health was the number one topic for all three age groups, which was “in accord with other studies of the information needs of older people” (p. 113). The second topic of concern to all respondents was income and finance. Recreation was the third. Other topics included government, consumer, housing and accommodations, retirement benefits (“concessions”), crime and safety, environment, pharmaceuticals, holidays, legal, transportation, family and personal, education, employment, services (e.g., Meals on Wheels), and volunteer opportunities.
In relation to source use, Williamson (1995, 1998) concluded that older persons, in general, relied most heavily on people within their social networks to keep them informed for their everyday lives. The young-aged were the biggest users of media sources, while the oldest two age groups set particular store by professionals (especially in the medical field) for meeting key information needs. They also appeared to be more reliant on family members than they were on other information sources. Friends were not a key information source for some of the very old, particularly because they were becoming increasingly isolated due to failing health and the loss of friends through death or other circumstances. Also, they sometimes appeared to be unable to sustain the effort needed to maintain friendships. The Internet had not emerged as a major information tool when Williamson conducted her study. The sources used by participants, analyzed according to whether purposeful or incidental information was involved, became an important part of the ecological model, as discussed in the “Use of Ecological Theory.”
The Use of Ecological Theory
Williamson’s (1995, 1997, 1998) study was largely inductive, meaning that it did not begin with a theory to test but rather aimed to develop theory grounded in the data, although theory from the literature played a part in the theory that emerged. In reviewing the literature, Williamson discovered that ecological theory had been used to good effect in a range of fields, including the psychology of aging. For example, citing Bronfenbrenner’s (1979) ground-breaking work, Birren and Birren (1990) promoted the use of ecological theory in the study of aging. They argued that such an integrative theory would have great explanatory power and would enable increases, declines, or stabilization of individual abilities, needs, preferences, or behaviors to be understood in relation to advancing age. Likewise, Kenyon (1988) made a case for the use of ecological theory for the study of older people, arguing that research on older people must be grounded in a view of nature as personal existence, which means that human persons are not conceptualized exclusively as either individual entities or socially constructed entities; rather, they are self-creating, but within contexts that involve various kinds of biological and social constraints. Being human thus involves a dialectical process of negotiating the self within social-environmental constraints (Hummert, Nussbaum, & Wiemann, 1992), a view consistent with theories of communication, including constructivism. For example, according to Berger and Luckman, in their ground-breaking The Social Construction of Reality (1967), “the relationship between man, the producer, and the social world, his product, is and remains a dialectical one” (p. 61). The ecological approach therefore encourages the investigation of individual and group needs within a social and environmental context.
Williamson (1998) decided to develop an ecological model, using the commonly used concentric circle approach, to try to portray her findings about her participants’ sources use diagrammatically. The model, Ecological Model of Information Seeking and Use (1), showed the range of influences on sources use by participants in the study—from the individual’s personal characteristics, values and lifestyles, to physical environments and socioeconomic circumstances, with wider societal factors also playing their part. She also used this model to indicate those sources which readily provided some information incidentally (e.g., family, friends, and the mass media—although these sources were also used with intent) and those from which information was mostly learned as a result of purposeful information seeking (e.g., information centers and libraries).
A Broader and Modified Ecological Model
In the years that followed her original study, Williamson undertook many funded projects which helped to indicate how her ecological model can be broadened and modified, to be useful to study information-related and communication behavior for a wide range of topics and participant cohorts. She has particularly used both social constructionist theory (Berger & Luckmann, 1967; Schwandt, 2000) and personal constructivist theory (Kelly, 1963) to capture both shared and individual meanings—the consensus and the dissonance—about information seeking and communication. The ecological framework is always important. For example, in one study, “An Intelligent, User-Sensitive Portal to Breast Cancer Knowledge Online” (Williamson, 2005a, 2005b; Williamson & Manaszewicz, 2002), the researchers set out to understand potential user perspectives regarding a range of information issues. Several “ecological” elements were found to play a part, including in promoting or impeding information seeking. Examples are biological factors/physical health, age, ethnicity, place of residence (city/country), stage of disease, and affective issues. With regard to age, for example, younger women felt strongly that their specific information needs were not well understood or catered for, because of their minority status among women with breast cancer. With regard to the effect of education, Williamson and Manaszewicz found that several studies (e.g., Beaver & Luker, 1997; Berland et al., 2001) assumed that patient education materials should be aimed at the eighth grade level or below when “most patient education materials are written at the tenth grade level or higher” (D’Alessandro, Kingsley, & Johnson West, 2001, p. 807). In fact, Williamson and Manaszewicz (2002) found that neither level is appropriate to all information seekers, which was unsurprising given that, at the time of their study, 30% of the Australian population had completed tertiary education.
The outcome of the Williamson and Manaszewicz (2002) study was that the capability of tailoring information to user needs through a portal called Breast Cancer Knowledge Online (http://www.bckonline.monash.edu.au) was developed. According to the website, “the project has designed and prototyped a web-based user-sensitive portal capable of matching user-aware resource descriptions and user needs profiles to provide differentiated access to breast cancer knowledge online.”
The concentric circle diagram (Figure 1, Ecological Model of Information Seeking and Use (2)) was modified after the breast cancer project to be more inclusive and complex than the original version, which had been developed for the project on the information seeking and communication of older people. It is important to note that the model, as was the case of the first one, is only loosely based on the Bronfenbrenner model. It does not use structures or systems are important, considered important by Bronfenbrenner and others. In this model, the information aspects are differentiated by the various circles: information needs, sources of information, and information use/knowledge. The influences on behavior are undifferentiated on the perimeter. As Sallis et al. (2008) pointed out, while there are multiple factors at different levels that influence specific health behaviors, “influences on behaviors interact across these different levels” (p. 466), meaning that the influences do not necessarily cluster into discrete categories.
Like all models, the ecological model is reductive, meaning that the descriptive details that accompany the model are crucial. It is important to note that the ecological model is not one that provides quantifiable impacts, though there may be some quantitative data emerging from the research that underpins it. Like the qualitative research on which it is usually based, at least in the present context, it provides rich insights into influences on behavior, rather than precise measurements of those influences.
A strength of the model is that it is possible to rearrange the components of the model, as seen in Figure 1, so that the influences are portrayed within the concentric circles and the sources of information/communication are on the periphery of the largest circle. Asla (2013), basing his research on that of Williamson (1995, 1997, 1998), restructured the model to do this (See Figure 1.)
The major strength of the model shown in Figure 1 is its flexibility to include all influences on behavior at any stage of the information-seeking or communication process for any cohort/s. The model has been useful for research involving many different academic and industry partnerships, topic areas, and target groups, including online investors where a range of specific factors had an important impact on use of information sources and where there were health and risk avoidance issues (see Williamson, 2008; Williamson & Kingsford Smith, 2010), people with disabilities (e.g., Williamson, Schauder, & Bow, 2000) and members of the International Olympic Community. Influences on information and communication emerge from each study undertaken and can be plotted diagrammatically on a model according as appropriate, arranged by levels or structures or not.
Use of the Ecological Model in a Study of the Fourth Age
Asla (2013) used an ecological approach in his study of the information-seeking and communication behavior members of the Fourth Age in two retirement communities in the mid-west of the USA, building on Williamson’s (1995, 1997, 1998) work. The Fourth Age, or disability zone, describes people who have multiple disabilities and are usually in the last stage of their lives. The physical, cognitive, and social losses of the Fourth Age have significant impact on human information behavior (HIB).
In introducing his ecological model, Asla (2013) pointed out that, by comparing Williamson’s (1998) model with his, it becomes clear that “one of the strengths of the ecological model is its flexibility” (p. 192). As pointed out, above, Alsa reversed the position of the factors influencing the behavior of his cohort so that they appeared in the concentric circles and the sources on the periphery of the largest circle. In pointing out how models need to reduce the story to key points, he made a comparison to the making of a movie from a novel. The movie condenses and combines elements from the book in order to tell a comprehensible visual story, clearly and succinctly. Models also do this to a story but the reduction is even more extreme.
In Figure 2, the labels for the concentric circles are appropriate to the Fourth Age study, in precisely the way that the circles in Sallis et al.’s (2006) model, “Ecological Model of Four Domains of Active Living,” are designated in ways that are appropriate to the active living study. Standard generic labels are not used. The Fourth Age study found that the individual’s ability to seek, process, and share information is most strongly impacted by the growing number of losses associated with increasing morbidity in the Fourth Age: personal factors (emotions, cognitive abilities, and physical abilities), followed by external factors (values, education, socioeconomic status, the individual’s increasingly small world environment, in this case the environment of the retirement community, and the outside world environment). The order of the circles is important: it indicates the relative importance of the influences on behavior as revealed in the study.
Asla (2013) added another dimension to Williamson’s (1995, 1997, 1998) purposeful/incidental information types. He found that all of the members of the Fourth Age in his study employed proxy information seekers (people who seek information on their behalf) when information was needed from “outside professional/institutional sources” and “computers/Internet.” For example, institutional sources such as government agencies were almost always approached by proxy information seekers. Most often the proxy information seeker was the individual’s caregiver, a family member or close friend, although computer center staff members working in a retirement community might sometimes seek information on behalf of a resident; for example look up Internet information. The tiny circles on the lines connected to those sources indicate that proxy information seeking may be involved.
Although the key aim of this piece is not to discuss research about information sources used by information seekers, research on this topic happens to have been used to build ecological models. A useful concomitant may be that the findings of the research have some relevance to communication of health and risk messaging. Understanding sources used in information seeking by various cohorts enables messages to be positioned in useful ways. For example, newspapers (hard copy) were very popular with the young-aged in the Williamson (1995, 1997, 1998) study. Although the data were collected a long time ago, it is likely that hard copy newspapers are still popular with older people, many of whom are still not Internet users, at least to the extent that younger people are. Newspapers are likely to still be a good way to communicate health and risk messages to older people. The papers cited in this essay are available for more detailed accounts of information sources preferred by older people, people with breast cancer, and people in the Fourth Age.
While the ecological approach is initially theoretical, it can be useful as a way to help conceptualize influences on particular communities before deciding on health communication and risk messaging. Research and practice should be closely linked: “Theory, research, and practice are a continuum along which the skilled professional can move with ease” (Glanz, Lewis, & Rimer, 1997, p. 19). Research about the individual/social/cultural/environmental factors that are influential regarding health and risk taking, and then plotting those on an ecological model, can be powerful, whether they are portrayed according to Bronfenbrenner’s systems, if appropriate, or in a way which reflects the terms of the particular study involved.
As mentioned and demonstrated several times in this essay, the advantage of the ecological-social model is its flexibility: it can be developed to include concepts that are important to a particular study or to the outcomes hoped for in terms of health and risk messaging. The quality of the research which underpins the model, and which necessarily focuses on individual and group experiences, however, is the key to useful outcomes. Then careful consideration needs to be made about the best approach: whether broad data which can be collected through a survey will provide the best indications of the influences on behavior; or whether in-depth perspectives from a qualitative approach may bring a greater understanding; or whether a mixed methods approach will provide the strengths of both. If good-quality research suited to ecological modeling has been undertaken, such modeling will facilitate better understanding of the multiple factors involved and aid decisions about potential actions.
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