SOCIAL SITUATION
3.9 Multi-level approaches to primary care problems
Having spent a substantial fraction of this book so far persuading you to be clear about the underpinning discipline and underlying theory which you are using to explain your observations or inform the design of an interven- tion, and about your research method and unit and level of analysis (see Section 3.7), I am now going to offer you examples of approaches that incor- porate multiple theories and which also require multiple methods, multiple units of analysis and multiple levels of analysis. As a primary care practi- tioner, you are probably already well aware that a typical problem in your clinical practice might be addressed on a number of levels, and that the most effective intervention is likely to address more than one level. Multi-level the- ories are becoming very popular in epidemiological research following the failure of simple interventions in research studies. Here, I briefly introduce one multi-level theory to illustrate the power of the approach: Stokols’ social ecology theory.
Social ecology theory, which has been widely used in studies of health pro- motion in primary care, was developed by (among others) David Stokols.52The term ‘ecology’ refers to ‘the study of the relationship between organisms and their environments’.52The theory includes an emphasis on biological processes, phys- ical health, geographical space, psychological aspects of behaviour choices, individual identity and the wider social, institutional and cultural contexts of people–environment relations. It has close parallels with general systems theory and complexity theory, both of which use ‘ecological’ metaphors to describe the dynamic interrelationship of multiple variables at multiple lev- els (and the need for empirical and analytic methods that can embrace this complexity).
According to Stokols, social ecology theory is built on four principles:
rMultiple facets: multiple aspects of the individual (such as genetic predispo- sition and psychological traits), the physical environment (such as geography, architecture and technology) and the social environment (such as social networks) interact dynamically to produce an overall effect on individual behaviour. Examples of such multiple dimensions include physical health sta- tus, emotional well-being, social cohesion, development maturation. Human experience and behaviour in the real world cannot be meaningfully studied in terms of any one of these influences alone.
rMultiple dimensions: Environments may be characterised in terms of a num- ber of dimensions such as: (a) physical and social features, (b) objective (actual) or subjective (perceived) qualities of these and (c) scale or immediacy to indi- viduals and groups. Emotional well-being, for example, may be influenced not just by the physical aspects of people’s environment but also by the perceived predictability, controllability, novelty and symbolic values of this environment.
rInterdependence: People influence their environment, which in turn influences the people who live there. The key to understanding transactions between people and their environments is grasping the recurrent (and often complex) cycles of mutual influence that occur.
rNon-linearity: Using a concept from general systems theory, the social eco- logical system contains multiple (positive and negative) feedback loops, which means that sometimes, small things can have big effects and vice versa. The effectiveness of an intervention directed at the health of a community can be increased substantially through the coordination of individuals and groups acting at different levels. Because of this, social ecological research generally requires diverse methods and multiple levels of analysis.
An important principle of social ecology theory, known as differential dy- namic interplay, is that environmental factors may affect different people dif- ferently depending on such factors as personality, health practices, perceptions of the controllability of the environment and financial resources. Stokols pro- posed that the level of congruence (or compatibility) between people and their surroundings is an important predictor of well-being.
Because of its explicit inclusion of multiple perspectives (psychology, sociology, social geography, social epidemiology), social ecology theory is inherently interdisciplinary and requires the integration of multiple levels of intervention and analysis (e.g. ‘macro’ level preventive strategies at the level of fiscal policy and public health, as well as ‘micro’ level individual interventions in primary care). The approach is, as might be expected, methodologically di- verse, including epidemiological surveys, environmental recordings, physical examinations, questionnaires and behavioural observations. In Section 8.4.3, I describe an adaptation of social ecology theory – Glass and McAtee’s ‘stream of causation’ theory – in relation to a discussion on the social determinants of health. In Section 5.4, I discuss another important multi-level theory, Engel’s biopsychosocial model of illness, which underpins the patient centred clinical method.
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CHAPTER 4