The Social Ecological Model
The Social Ecological Model was initially used as a framework to understand human development in the 1970s (Kilanowski, J. F., 2017). Urie Bronfenbrenner introduced this model as nesting circles surrounding an individual, where these circles influence an individual, with the innermost parts being the strongest influences (Kilanowski, J. F., 2017). The influence in the closest circle is the person’s relationships and immediate surroundings, also known as individual influences, followed by the second circle, which would influence where the person has direct contact, also known as community. Lastly, the third influence would be internal and external factors which would be considered environmental (Kilanowski, J. F., 2017). Various sources have since shaped this model, including the Centers for Disease Control (CDC), to represent interpersonal, organizational, community, and policy rather than merely individual, community, and environment (Kilanowski, J. F., 2017). The CDC uses this updated version of the SEM to understand the factors influencing violence in an attempt to prevent it (Centers for Disease Control, 2021). Using individual, relationship, community, and societal levels as overlapping circles, they can better understand why a person would be at risk for violence and how they can protect them from it (Centers for Disease Control, 2021). This model can be applied to many different situations to determine how to prevent and protect a person from a specific condition or situation.
You can see the overlapping circles of the model in the figure below:
Source: Centers for Disease Control. (2021). The Social-Ecological Model: A Framework for Prevention. Retrieved from https://www.cdc.gov/violenceprevention/about/social-ecologicalmodel.html
Each circle can be used to understand a factor that will influence a person:
Individual: This first level of the SEM describes what influences a person at an individual level. Such as history and biology. For example, with diabetes, a person may be at a higher risk for type 2 diabetes based on their weight, family history, gender, etc.
Relationship: This second level of the SEM is the relationships closest to a person and how they can influence them. Some of these relationships may include teachers, family, friends, coworkers, etc. Using diabetes as an example again, to prevent diabetes a person could receive support and education about preventing type 2 diabetes from any of these relationships.
Community: The third level of the SEM would be communities and organizations that can influence a person. For example, a community can decide to start offering educational programs through schools relating to diabetes prevention with programs that teach healthy eating and exercise to help prevent type 2 diabetes. It is also essential to evaluate these settings to determine the prevalence of specific thoughts or actions. For example, looking at the culture around healthy eating within this community and choose what and how it can be improved.
Social: The SEM's final level is considered to be the laws and regulations in a population surrounding a specific subject. For example, food businesses in Ontario must post a disclaimer stating how many calories adults and children need per day and post the number of calories in food on their menus to help people make more informed nutritional choices (Government of Ontario, 2019).
For a brief overview of the Social-Ecological Model, the MCH Training program -UTHealth School of Public Health has created a great video that can be found here: https://www.youtube.com/watch?v=5NNw0GSUR-c
What is Diabetes?
To dive a little bit further into using the Social Ecological Model to prevent type 2 diabetes within a population, we must first understand diabetes. Diabetes is a condition where the body cannot properly process food to be used as energy (Centers for Disease Control and Prevention, 2020). For a person without diabetes, the human body will take food and turn it into glucose or sugar that our bodies can use for energy (Centers for Disease Control and Prevention, 2020). This glucose needs a hormone called insulin to help it get into the cells to be used by our bodies for energy (Centers for Disease Control and Prevention, 2020). When a person has diabetes, they either aren't producing enough insulin, or their body doesn't use the insulin as efficiently as it should (Centers for Disease Control and Prevention, 2020). This deficiency causes the glucose to build up within the bloodstream, leading to many serious complications, including kidney failure, heart disease, blindness, and lower-extremity amputations (Centers for Disease Control and Prevention, 2020). There are three main types of diabetes, Type 1, Type 2, and gestational diabetes (Centers for Disease Control and Prevention, 2020). Type 1 diabetes is caused by an autoimmune reaction that causes the body to stop producing insulin. Type 2 diabetes is when your body cannot properly use the insulin produced. This is usually caused by unhealthy lifestyle factors and some non-modifiable risk factors and develops over many years (Centers for Disease Control and Prevention, 2020). Gestational diabetes is a type of diabetes that develops in pregnant women who have never had diabetes before and usually goes away after birth (Centers for Disease Control and Prevention, 2020).
Risk Factors for diabetes
The risk factors for Type 1 diabetes are still unknown, but there are many known risk factors for Type 2 diabetes (Centers for Disease Control and Prevention, 2020). Some of these risk factors include prediabetes, being overweight, being 45 years or older, having a family member with type 2 diabetes, having a lower level of income or education, lack of physical activity (less than three times a week), and being African American, Hispanic/Latino American, American Indian, or Alaska Native (some Pacific Islanders and Asian Americans are also at higher risk) (Centers for Disease Control and Prevention, 2020). There are also many factors relating to social determinants of health that can influence whether someone develops diabetes in their life. These factors include education, food security, income, social support, environment, and healthcare access.
Diabetes and SEM
When considering prevention and treatment for type 2 diabetes, the Social Ecological Model could be a great resource to identify areas of concern and improvement. As previously stated, the risk factors for type 2 diabetes include both modifiable and non-modifiable factors; using the SEM to influence the modifiable risk factors could be a huge step forward in diabetes prevention. These prevention and improvement possibilities were shown by McElfish PA, et al., who looked into diabetes prevention and management among pacific islanders in Arkansas, who happen to have one of the highest rates of type 2 diabetes. Their findings determined that the people within this community were not receiving the proper community and policy level support to prevent and manage type 2 diabetes, and recommended they include social ecological resources at these levels to assist with prevention and treatment (McElfish PA et al., 2016). Similar findings were published when Barrera, M, et al., used a Mediterranean lifestyle program on post-menopausal women with type 2 diabetes that included social-ecological resources as mediators of intervention (Barrera, M, et al., 2008). The study results determined that social-ecological interventions can contribute to healthy lifestyle improvements in the study subjects (Barrera, M, et al., 2008). As shown with these two studies, when all Social Ecological Model factors are used in preventative and treatment methods for a disease condition, the outcomes are likely to be more favorable.
References
Barrera, M., Jr., Strycker, L. A., MacKinnon, D. P., & Toobert, D. J. (2008). Social-ecological resources as mediators of two-year diet and physical activity outcomes in type 2 diabetes patients. Health Psychology, 27(2, Suppl), S118–S125. https://doi.org/10.1037/0278-6133.27.2(Suppl.).S118
Caperon L, Arjyal A, K. C. P, Kuikel J, Newell J, Peters R, et al. (2019) Developing a socio-ecological model of dietary behaviour for people living with diabetes or high blood glucose levels in urban Nepal: A qualitative investigation. PLoS ONE 14(3): e0214142. https://doi.org/10.1371/journal.pone.0214142
Centers for Disease Control and Prevention. (2020). Diabetes Basics. Retrieved from https://www.cdc.gov/diabetes/basics/diabetes.html
Centers for Disease Control and Prevention. (2020). Diabetes Risk Factors. Retrieved from https://www.cdc.gov/diabetes/basics/risk-factors.html
Centers for Disease Control. (2021). The Social-Ecological Model: A Framework for Prevention. Retrieved from https://www.cdc.gov/violenceprevention/about/social-ecologicalmodel.html
Chang, J., Guy, M. C., Rosales, C., de Zapien, J. G., Staten, L. K., Fernandez, M. L., & Carvajal, S. C. (2013). Investigating social ecological contributors to diabetes within Hispanics in an underserved U.S.-Mexico border community. International journal of environmental research and public health, 10(8), 3217–3232. https://doi.org/10.3390/ijerph10083217
Diabetes Canada (2020). Diabetes in Canada. Retrieved from https://diabetes.ca/DiabetesCanadaWebsite/media/Advocacy-and-Policy/Backgrounder/2020_Backgrounder_Canada_English_FINAL.pdf
Government of Ontario. (2019). Calories on menus: information for businesses. Retrieved from https://www.ontario.ca/page/calories-menus-information-businesses#:~:text=You%20must%20post%20the%20following,However%2C%20individual%20needs%20vary.
Kilanowski, J. F. (2017). Breadth of the Socio-Ecological Model. Journal of Agromedicine, 22:4, 295-297, DOI: 10.1080/1059924X.2017.1358971
McElfish PA, Moore R, Woodring D, Purvis RS, Maskarinec GG, et al. (2016) Social Ecology and Diabetes Self-Management among Pacific Islanders in Arkansas. J Fam Med Dis Prev 2:026. 10.23937/2469-5793/1510026
MCH Training program -UTHealth School of Public Health. (2017, Feb 6). Intro to the Ecological Model [Video]. Youtube. https://www.youtube.com/watch?v=5NNw0GSUR-c
Mentock, S., Vanessa Y. Ng, Narayana, R., Ullal, H., Kumari, S., Badiger, S., Shetty, A. (2017). Treatment-seeking behavior and obstacles to treatment compliance in diabetic patients in Mangaluru, India. Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 11(2), 617-622. Retrieved from https://doi.org/10.1016/j.dsx.2017.04.014.
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