How are Community services developed? A Multilevel Approach to Health ...

(Michael Stellefson, 2019)

In my research on this topic, initially, I found it overwhelming to try to understand what the term multilevel model of health" meant and then apply that to my professional area in community health. I discovered that a multilevel approach is multi-faceted, meaning five layers comprise the structure of a community as a whole. In this case, the applicable model is the social-ecological model. “The Socio-Ecological Model takes into consideration the individual, and their affiliations to people, organizations, and their community at large to be effective. There are five stages to this model – Individual, Interpersonal, Organizational, Community, and Public Policy” ("Core principles of the ecological model | Models and mechanisms of public health," n.d.)

Community is defined as any group of people who share geographic space, interests, goals, or histories. Changes in social and physical features of the environment constitute valued outcomes for community-based prevention because the distributions of risk factors, health outcomes, and wellness indicators in a population are largely shaped by social and physical environments” (“An Integrated Framework for Assessing the Value of Community-Based Prevention,” 2012). Furthermore, the final layer, the societal level, upholds policymakers, government bodies, and municipal entities to create and support the appropriate services, safety measures, businesses, housing models, and food securities. "For examining the contexts of health behavior, this model framework accounts for behavioral control, community norms and beliefs, interpersonal influences, organizational settings, and power structures” (MITRE Corporation, 2021).

In the study conducted by Golden et al. (2015), the authors aim to underscore the complexity of real-world structural interventions, teaching us that policy and environmental change are neither easy nor guaranteed to be effective. The authors suggest that over the past several decades, there has been an increase in efforts to modify laws and settings in which people live, work, and play. However, there are not many frameworks for health promotion that show the intricate mechanisms to modify structures that improve health (Golden et al., 2015).

Every day, we, as individuals, make decisions. Sometimes they are quick and on the spot, while other times they have to be well thought out or require some effort. The connections we develop over time, as well as the social and physical environments we live in, impact every decision we make, but we do not often realize this or notice that our decisions may ultimately shape our health outcomes. To put this into context, for example, at the rise of the COVID-19 pandemic, the public was faced with having to decide whether to accept a vaccine. In making that choice, the final decision would likely have been influenced by:

· Our personal beliefs (individual)

· Whether trusted family members or friends have chosen to take it personally

· The work environment we encounter as teachers, nurses, physicians, or other

fields (institutions and organizations)

· Advocacy from the organizations we’re a part of (community), or

· Our confidence and trust in the federal government may (Structures and Systems)

(W, 2021).

(W, 2021)

Community-based prevention remains apart from other forms of action due to certain characteristics that have been developed and examined over the past fifty years by public health research and practice. Population health is the main goal of community-based preventive interventions, which may also emphasize context, highlight community empowerment and participation, address changes in the social and physical environment, or use a systems approach (National Academies Press (US), 2012). Changes in individual characteristics are not the main goal of community-based prevention. Rather, "the health outcomes of a group of individuals, including the distribution of such outcomes within the group," or "population health," is the focus. (Kindig and Stoddart, 2003, as cited in National Academies Press (US), 2012). As a result, various public health groups or organizations are then funded by their governments to carry out interventions. One example of the role played by such organizations would be “community activation” (Community Activation Playbook | Resources for Public Health Experts, n.d.).

(Community Activation Playbook | Resources for Public Health Experts, n.d.),

Community activation uses a range of strategies, including education, screening, immunization campaigns, health promotion initiatives, and behavioral interventions (Community Activation Playbook | Resources for Public Health Experts, n.d.). Subsequently, community-based interventions aim to lower the burden of illness and disability by addressing important health issues and risks. These interventions are initiated and monitored to maintain a community’s good health and wellness. The approaches are applied in collaboration with community sources, health centers, and/or businesses, and they are modified to address local health concerns accordingly (Pub, n.d.). The challenges that may arise from the planning and implementation of such activations and interventions would be related to the community’s determinants of health.

The Canada Public Health Agency acknowledges that when individuals are ill, they expect to receive comprehensive, easily accessible, and high-quality medical care. Canadians value services and supports that are effective in preventing and promoting their health. “Doing this will improve the quality of life of Canadians while reducing disparities in health and the impact these conditions have on individuals, families, communities, the health-care system, and society" (2010, p. 2). In a more recent posting on their website, the Canada Public Health Agency (2023) discusses “Social determinants of health and health inequalities” (para. 1) and states that:

Determinants of health are the broad range of personal, social, economic, and environmental factors that determine individual and population health (Public Health Agency of Canada, 2023, para. 2).

The Public Health Agency suggests that within the larger category of determinants of health, social determinants of health pertain to a particular set of social and economic factors. These include things like money, education, and work that are related to a person's position in society. For some groups, including Black Canadians, LGBTQ people, and Indigenous Peoples, experiences with racism, discrimination, and historical trauma are significant social determinants of health (2023, para. 3).

(National Academies Press (US), n.d.)

Health inequity refers to health inequalities that are unfair, unjust, and modifiable. For example, Canadians who live in remote or northern regions do not have the same access to nutritious foods such as fruits and vegetables as other Canadians (para. 6). While Canada is known to be the healthiest nation in the world, some Canadians are in better health than others, depending on their level of access to health care and/or healthy living options. When the population has limited access to either of those factors, they are found to have health inequalities, which result in variations in their state of health (para. 5). Additionally, although Canada may be known to be the healthiest nation in the world, our Indigenous People continue to experience inequities. “[W]hen it comes to access to health care and health outcomes, the glaring disparities that separate Canada’s Indigenous and non-Indigenous populations cast an ugly shadow on the ranking” (Why Do Indigenous People in Canada Face Worse Health Outcomes Than non-Indigenous People?, 2021).

(National Academies Press (US), n.d.)

In a 2018 CBC News post Dr. Alika Lafontaine describes his experiences that present contradictions of Canadian health equity and the ineffective utilization of theSocial Ecological model. He indicates that despite talks going back to 2016 when “Truth and Reconciliation Calls to Action for health … had yet to make its way into health decision-making circles … there wasn't much optimism from anyone that transforming Indigenous health was an achievable task” (Lafontaine, 2018).

Continuing into 2018:

Crises continue[d] unabated in Indigenous communities. National medical organizations and provincial health regions remain[ed] hesitant to aggressively address health service inequities, instead waiting for the federal government to act or fill the deafening silence. Health disparities continue[d] to widen and most of the T[ruth] [and] R[econciliation] C[omission] actions … for health care remain[ed] unfulfilled, or only partially delivered (2018).

As a response to addressing health inequalities for Canadians, the Canada Public Health Agency aims to provide all Canadians “the same opportunities to be healthy, no matter who they are or where they live” (Public Health Agency of Canada, 2023, para. 8). There are several measures listed on their website Social determinants of health and health inequalities, outlining the strategies to address the social determinants of health and thereby lessen health disparities (para. 9).

Health equity is the absence of unfair systems and policies that cause health inequalities. Health equity seeks to reduce inequalities and increase access to opportunities and conditions conducive to health for all (para. 7). For the Indigenous Peoples, it appears the efforts of Indigenous campaigners such as Dr. Lafontaine, are finally starting to see the actions coming to play. An example of one recent mitigation addressed by the current Canadian Prime Minister, Justin Trudeau is presented in this video: Investing in and delivering better health care for First Nations in British Columbia - YouTube

(Justin Trudeau – Prime Minister of Canada, 2023)

Additionally, “the Government of Canada is responding to the Truth and Reconciliation Commission's Calls to Action 18 to 24 [of 94 calls to action]” to health (Government of Canada; Crown-Indigenous Relations and Northern Affairs Canada, 2023).

Circling back to the discussion on the Social Ecological Model, the resources and information curated for this blog demonstrate how our Canadian government has strategized policy-making and community-based initiatives to support and address the earlier mentioned five layers of the model for the individual, their social environment, physical environment, and policy.

(Health Resources, n.d.)

References

An integrated framework for assessing the value of Community-Based Prevention.

(2012). In National Academies Press eBooks. https://doi.org/10.17226/13487

Brown, A. (n.d.). Core principles of the ecological model | Models and mechanisms of

Public Health. https://courses.lumenlearning.com/suny-buffalo-environmentalhealth/chapter/core-principles-of-the-ecological-model/

Community Activation Playbook | Resources for Public Health experts. (n.d.).

https://communityactivation.mitre.org/

First Nations Health Authority. (2016, November 8). Social determinants of health

[Video]. YouTube. https://www.youtube.com/watch?v=ikNsoh5TtQE

First Nations Health Authority. (2019, July 16). The Social Determinants of Health from

a First Nation Perspective [Video]. YouTube. https://www.youtube.com/watch?v=aD-wYpDsooQ

Golden, S. D., McLeroy, K. R., Green, L. W., Earp, J. A., & Lieberman, L. D. (2015).

Upending the social ecological model to guide health promotion efforts toward policy and environmental change. Health Education & Behavior, 42(1_suppl), 8S-14S. https://doi.org/10.1177/1090198115575098

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(2023, September 29). Health. https://www.rcaanc-cirnac.gc.ca/eng/1524499024614/1557512659251

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https://www.canada.ca/en/health-canada/services/video/reconciliation.html

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Lafontaine, A. (2018, March 19). Close the gap between Indigenous health outcomes

and the rest of Canada. CBC. https://www.cbc.ca/news/indigenous/opinion-indigenous-health-alika-lafontaine-1.4547798

Michael Stellefson. (2019, May 14). Social ecological model [Video]. YouTube.

https://www.youtube.com/watch?v=1fJfZI5wlt0

National Academies Press (US). (n.d.). FIGURE 2-1, A guide to ecological planning of

community prevention programs. NOTE: The dotted lines between levels of the model denote interaction effects between and among the various levels of health determinants (Worthman, 1999). - An Integrated Framework for Assessing the Value of Community-Based Prevention - NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK206935/figure/fig2_1/?report=objectonly

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