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Title
Translating social ecological theory into guidelines for community health promotion.
Permalink
https://escholarship.org/uc/item/2bv79313
Journal
American journal of health promotion : AJHP, 10(4)
ISSN
0890-1171
Author
Stokols, D
Publication Date
1996-03-01
DOI
10.4278/0890-1171-10.4.282
Copyright Information
This work is made available under the terms of a Creative Commons Attribution License,
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THE
Culture Change
Translating Social Ecological Theory into
Guidelines for Community Health Promotion
Daniel Stokols
Abstract
Health promotion programs often lack a clearly specified theoretical foundation or are
based on narrowly conceived conceptual models. For example, lifestyle modification programs
typically emphasize individually focused behavior change strategies, while neglecting the
environmental underpinnings of health and illness. This article compares three distinct, yet
complementary, theoretical perspectives on health promotion: behavioral change, environmen-
tal enhancement, and social ecological models. Key strengths and limitations of each perspec-
tive are examined, and core principles of social ecological theory are used to derive practical
guidelines for designing and evaluating community health promotion programs. Directions
for future health promotion research are discussed, including studies examining the role of
intermediaries (e.g., corporate decision-makers, legislators) in promoting the well-being
others, and those evaluating the duration and scope of inteqvention outcomes. (Am J Health
Promot 1996;1014]:282-98.)
Daniel Stokols, PhD, is professor and dean of the School of Social Ecolo~ at the University of
California, Irvine, Irvine, California.
Send reprint requests to Daniel Stokols, Dean, School of Social Ecology., University of California,
Irvine, Irvine, CA 92717-5150.
Submitted January 19, 1994; revisions requested April 3, 1995; accepted for publication Augustl, 1995.
Copyright © 1996 by American Journal of Health Promotion, Inc.
0890-1171/96/$5.00 + 0 67/1/68996
OVERVIEW
The past 15 years have witnessed a
tremendous growth in health promo-
tion research and practice. This
quantitative growth in research and
intervention programs has been
accompanied by a qualitative shift in
emphasis from individually oriented
analyses of health behavior to those
that encompass environmentally based
as well as behaviorally focused strate-
gies of health promotion. Whereas the
1979 Surgeon General’s Report on Health
Promotion and Disease Prevention
~
emphasized the modification of
individuals’ health habits and lifestylesl
more recent conceptualizations have
stressed the importance of linking
behavioral strategies of health promo-
tion with efforts to strengthen environ-
mental supports within the broader
community that are conducive to
personal and collective well-being,
z,3
The shift from person-focused to
environmentally based and commu-
nity-oriented health promotion is
evident in several streams of research,
including the development of cultural
change strategies to foster socially
supportive norms and healthful
environmental conditions within work
organizations;
4’5
community-wide
efforts to facilitate citizen participation
in the development and implementa-
tion of health promotion programs;
e’l°
and the Healthy Cities Movement,
which has evolved from sustained
international collaboration in the
design and delivery of community
health promotion programs?
~’~2
These
areas of research all reflect the
increasingly ecological orientation of
the health promotion field.
"~,a~’16
The
increased popularity of the ecological
orientation stems from a growing
282 American Journal of Health Promotion
recognition that most public health
challenges (e.g., encouraging people
to exercise regularly, improve their
diet, and refrain from smoking) are
too complex to be understood ad-
equately from single levels of analysis
and, instead, require more compre-
hensive approaches that integrate
psychologic, organizational, cultural,
community planning, and regulatory
perspectives?
7-1u
This article examines the core
assumptions and principles inherent in
the social ecological approach to
health promotion. Social ecology is
viewed as an overarching framework,
or set of theoretical principles, for
understanding the interrelations
among diverse personal and environ-
mental factors in human health and
illness. The article also considers some
of the ways in which social ecological
theory can be used to develop practical
guidelines for designing, implement-
ing, and evaluating community health
promotion programs. The assumption
here is that social ecological theory
offers a variety of conceptual and
methodologic tools for organizing and
evaluating health promotive interven-
tions.
I begin with an overview of the core
assumptions and distinguishing
features of three alternative, yet
complementary, perspectives on
health promotion:
¯
Behavioral change and lifestyle
modification
¯
Environmental enhancement and
restructuring
¯
Social ecological analyses of health
promotion
In many respects, the social ecologi-
cal approach integrates person-focused
efforts to modify persons’ health
behavior with environment-focused
interventions to enhance their physical
and social surroundings. Yet the social
ecological approach goes beyond
behavioral and environmental change
strategies by offering a theoretical
framework for understanding the
dynamic interplay among persons,
groups, and their sociophysical
milieus. Thus the latter portions of this
article emphasize the translation of
social ecological theory into practical
guidelines for community health
promotion.
BEHAVIORAL, ENVIRONMENTAL,
AND SOCIAL ECOLOGICAL
APPROACHES TO HEALTH
PROMOTION
The 1979 Surgeon General’s Report on
Health Promotion and Disease Prevention
~
was instrumental in alerting the
American public to the impact of
unhealthy behaviors, such as smoking
and substance abuse, on personal and
community well-being. As clinical
evidence for the links between
smoking, lung cancer, and cardiovas-
cular disease mounted during the
1970s and 1980s, the prevailing view of
health as merely the "absence of
illness
’’~°
and the corresponding
emphasis on medical interventions to
remediate disease began to be chal-
lenged by broader conceptions of
health as "complete physical, emo-
tional, and social well-being
’’~
and
supplemented by preventive strategies
for modifying unhealthy behavior and
lifestyles before the onset of illness
symptoms.
22-25
Whereas earlier approaches to
health enhancement had focused
ahnost exclusively on the medical
treatment of disease, the 1970s and
1980s saw a growing interest in
disease prevention, health protec-
tion, and health promotion pro-
grams. The terms disease prevention
and health protection have been used
to describe various medical and
public health strategies aimed at
preventing the onset of physical and
mental illness (e.g., inoculation
against infectious diseases, enhanced
community sanitation services,
reduction of workplace hazards, and
governmental regulation of food and
drug safety). The concept of health
promotion, however, differs from the
disease prevention orientation in
that it places greater emphasis on the
role of persons, groups, and organi-
zations as active agents in shaping
health practices and policies to
optimize both individual wellness
and collective well-being.
~,21,26
Of
particular relevance to this discussion
is community health promotion, which
emphasizes collaborative efforts
among various public and private
sectors to enhance the well-being of
a population within a geographically
defined area.
~
Behavioral Change Strategies of
Disease Prevention and Health
Promotion
The behavioral change approach to
disease prevention and health promo-
tion focuses on the modification of
persons’ health-related behaviors.
Examples of these behaviors are
dietary and exercise regimens, smok-
ing and alcohol consumption, safe or
unsafe sexual practices, and personal
actions that either decrease or increase
the likelihood of bodily injury (e.g.,
vehicle safety belt and bicycle helmet
usage, firearm purchases, substance
abuse). During the 1970s, several
studies documented the empirical
links between persons’ routine health
practices, stressful patterns of living,
and their susceptibility to disease and
premature death37--~° These research
programs further suggested that
personal vulnerability to disease
increases in proportion to the number
and regularity of unhealthy behaviors
performed by individuals.
People who regularly engage in
multiple health-threatening behav-
iors-for example, by smoking
cigarettes, consuming excessive
amounts of alcohol and saturated fat,
adopting irregular sleep and exercise
patterns, and experiencing chroni-
cally high levels of interpersonal
stress--are described as having
unhealthy lifestyles.
’~,~7,~1
Behavioral
change interventions to prevent
disease can focus on modifying single
patterns of unhealthy behavior (e.g.,
smoking cessation programs), or on
the replacement of unhealthy
lifestyles (characterized by interre-
lated clusters of behavioral risk factors
for disease) with healthier ones?
z
Efforts to modify individuals’
unhealthy behaviors and lifestyles
have been guided by several distinct
theories of social influence. Social
influence is the alteration of a
person’s thoughts, attitudes, and
behavior in response to the actions or
feelings of others)
~-s5
A substantial
amount of psychologic research has
focused on three basic forms of social
influence: cognitive changes involving
the alteration of a person’s beliefs
and opinions; affective changes
reflecting a shift in one’s evaluation
of some entity; and behavioral
modification involving changes in a
March/April 1996, Vol. 10, No. 4
283
person’s overt actions toward his or
her surroundings.
Theoretical and clinical perspec-
tives on modifying persons’ health-
relevant actions reflect varying degrees
of emphasis on cognitive, affective,
and behavioral processes. For ex-
ample, behavioral therapies based on
operant and classical conditioning
principles emphasize the manipulation
of nonsymbolic reinforcement
contingencies as the primary strategy
for changing personal health behav-
ior.
3e’~8
Alternatively, the health belief
model
"~9"4°
and theories of social
learning,
4~,42
self-efficacy,
4~
reasoned
action,
~
and planned behavior
4~
give
greater attention to the role of
cognitive and symbolic processes in
mediating personal behavior change.
The affective and motivational
underpinnings of people’s health
beliefs and behavior, on the other
hand, are explicitly emphasized in
theories of risk perception,
46’47
fear
arousal and self-protective behav-
ior,
48-~°
and learned helplessness
5~
and
in studies of disease-prone and disease-
resistant personalities,
52-’~4
and health
communications and mass media.
5~
Several lines of research have
demonstrated the effectiveness of
cognitive and behavioral modification
programs and educational and mass
media campaigns in diminishing
health-threatening actions and
personal orientations, such as the
coronary-prone behavior pattern,
56
and in promoting the adoption of
improved dietary, exercise, stress
management, and safety regimens)
7~
At the same time, however, certain
large-scale behavior change programs,
such as the Multiple Risk Factor
Intervention Trials (MRFIT) and the
Minnesota Heart Health Program to
reduce cardiovascular disease, have
had a modest or negligible impact on
persons’ health practices and health
status.
6’~67
The modest impact of these
interventions reveals some potential
limitations that are inherent in
behavior change models of health
promotion. First, persons’ efforts to
modify their own health practices are
often impeded by economic, social,
and cultural constraints. Low educa-
tional status, lack of time, money and
energy, chronic exposure to neighbor-
hood violence, and proximity to
friends and family members who
frequently exhibit health-threatening
behavior are some of the situational
factors that can derail people’s best
efforts and intentions to improve their
health practices.
3,~4,2~,68,6~
On the other hand, efforts to
persuade a person to adopt improved
health practices may go unheeded if
that person is unready or unmotivated
to enact the suggested behaviors.
7°, :~
And even when persons do manage to
adopt new and improved health
practices, the efficacy of their behav-
ioral changes can be undermined by
their exposure to environmental
toxins and safety hazards.
2’72-74
In recent years increasing attention
has been paid to the role of environ-
mental factors in human well-being, as
the result of growing public concerns
about the health impacts of indoor
and outdoor air pollution, soil and
water contamination, lead poisoning
in children, ultraviolet and electro-
magnetic radiation, dysfunctional
environmental design, global warm-
ing, and ozone depletion.
75"~
Health
promotion efforts based on environ-
mental enhancement strategies are a
crucial adjunct to individually focused
lifestyle modification programs. We
turn now to a consideration of envi-
ronmentally oriented models of health
promotion.
Environmental Change Strategies of
Health Promotion
Earlier discussions of health policy
in the United States have subsumed
environmental strategies of health
enhancement under the rubric of
health protection--that is, those
changes in the physical environment
that are undertaken to eliminate or
reduce toxic, pathogenic, or in~urious
conditions.
~’’~6
The analysis presented
in this paper, however, construes the
environments of persons and whole
communities as multidimensional,
encompassing social and cultural as
well as physical (e.g., geographic,
architectural and technologic)
components. Moreover, the environ-
ment is assumed to function not only
as a potential source of pathogens,
toxins, and safety hazards, but also as a
provider of health-promotive informa-
tion and social support that can enable
people to achieve higher levels of well-
being than are implied by the term
health protection (that is, avoidance of
unhealthful or unsafe environmental
conditions). In this discussion, there-
fore, the broader concept of health
promotion is used to refer to the full
array of environmentally based
strategies of health enhancement.
2,2~
Recent evidence for the health
impacts of global environmental
change
*2’aa
underscores the impor-
tance of developing environmentally
based strategies of health promotion
in conjunction with behavioral-change
and lifestyle-modification programs.
Environmental enhancement interven-
tions can be considered in relation to
at least five "envirogenic," or health-
influencing, functions of the physical
and social environment.
~
¯
The physical and social environment
can serve as a medium of disease
transmission, exemplified by
wa{erborne and airborne diseases
and the spread of contagious
illnesses through interpersonal
contact.
¯
The environment can operate as a
stressor, exerting detrimental effects
on people’s mood, performance,
and physiology as the result of their
exposure to uncontrollable demands
such as noise, political upheaval, or
interpersonal conflict.
¯
The environment can function as a
source of safety or danger (e.g.,
residing in areas that are chemically
contaminated, geographically
unsafe, or socially violent).
¯
The environment can serve as an
enabler of health behavior, exempli-
fied by the installation of safety
devices in motor vehicles, proximity
of physical fitness facilities to one’s
home or workplace, and exposure to
interpersonal modeling or cultural
practices that foster health-promo-
rive behavior.
¯
The environment can serve as a
provider of health resources such as
effective conamunity sanitation
systems, public health services, and
legislation ensuring citizens’ access
to health insurance and primary
care.
Environmental enhancement
strategies have emphasized these
health-related functions of the
284 American Journal of Health Promotion
environment to varying degrees,
depending on the theoretical or
disciplinary bases of the intervention
program. For example, the role of the
environment in transmitting disease
and as a source of safety or danger has
been emphasized in the fields of
industrial hygiene,
84
occupational
epidemiology,
s-~
injury control,
s6,s7
environmental health science,
75,76
and
environmental psychology,
as’s9
The stress-inducing and stress-
buffering qualities of environments
have been examined in studies of
social support, environmental stres-
sors, and well-being,
’~c~9~
and in the
fields of ergonoinics and human
factors)
c~us
The role of the environ-
ment as an enabler of health behavior
and as a provider of health resources,
on the other hand, has received more
attention in studies of organizational
development
9~-1°2
and in fields such as
architecture, facilities management,
geography, sociology, and urban
planning.75.m-~-~os
An important advantage of environ-
mental-enhancement models of health
promotion is that they provide a more
complete understanding of the
situational factors that can facilitate or
hinder persons’ efforts to improve
their health practices and well-being.
Moreover, environmental analyses
reveal the direct and often impercep-
tible effects of people’s physical and
social surroundings on their well-
being, which can undermine the
benefits of favorable health practices
or exacerbate the negative outcomes
associated with unhealthful and injury-
prone behavior.
Environmental enhancement
strategies of health promotion also
tend to be more powerful than
behavioral and lifestyle modification
programs, because they have the
capacity to benefit all persons exposed
to an environment rather than
focusing narrowly on improving the
health of one person at a time. For
example, environmentally based
health promotion programs typically
emphasize passive intevventions,
TM
or
those that simultaneously enhance the
health of several people without
requiring any voluntary and sustained
effort on their part (e.g., the use of
child-resistant caps on medicine
bottles; factory installation of airbags
in all new motor vehicles). Behavioral
change models, on the other hand,
emphasize active interventions that
require voluntmy and sustained effort
by persons as a prerequisite for
achieving the desired health benefits
(e.g., encouraging persons to give up
smoking and to engage in vigorous
physical exercise on a regular basis).
Thus, active interventions are usually
more difficult to maintain over
extended periods than passive inter-
ventions.
Like behavioral-change models of
health promotion, however, environ-
mentally based interventions reflect
some important limitations. First,
interventions aimed at improving
environmental quality typically have
focused on single facets of the
physical or social environment (e.g.,
indoor air quality, seismic hazards, or
social climate within work organiza-
tions) rather than examining multiple
environmental dimensions (e.g., both
physical and social conditions within
settings) and the relationships among
them. Second, environmental analy-
ses of health promotion give little or
no attention to the varying behavioral
patterns and sociodemographic
characteristics of the people occupy-
ing particular places and settings.
Clearly, the health-related value of
environmental enhancements (e.g.,
designating workplaces as "smoke-
free") may be diminished for those
people who continue to engage in
unhealthful activities (e.g., smoking
cigarettes at home and during lunch
breaks at work), or for those groups
who are more vulnerable to the
negative health impacts of environ-
mental hazards and stressors because
of their restricted income, educa-
tional level, and geographic mobility.
Thus, environmental approaches to
health promotion often neglect
individual and group differences in
people’s response to their socio-
physical milieu.
Having noted some of the strengths
and limitations associated with
behavioral change and environmental
enhancement strategies of health
promotion, we now consider the
ecological perspective that addresses
several of the limitations inherent in
the behavioral and environmental
approaches.
Social Ecological Models of Health
Promotion
The social ecological perspective on
health promotion is based, not on a
singular discipline or theory, but
rather on a broad, overarching
paradigm that bridges several different
fields of research. The term ecology
refers to the study of the relationships
between organisms and their environ-
ments)
°’~
Early ecological analyses of
the relations between plant and
animal populations and their natural
habitats
I~°’m
were later extended and
applied to the study of human commu-
nities and environments within the
fields of sociology, psychology, and
public health,
l~’nu~6
The field of social
ecology, which emerged during the
mid 1960s and early 1970s, gives
greater attention to the social, institu-
tional, and cultural contexts of people-
environment relations than did earlier
versions of human ecology, which
focused primarily on biologic pro-
cesses and the geographic environ-
ment.l~5,117,1~8
The social ecological paradigm is
rooted in certain core principles or
themes concerning the interrelations
among environmental conditions and
human behavior and well-being. First,
ecological analyses characterize
environmental settings as having
multiple physical, social, and cultural
dimensions that can influence a variety
of health outcomes, including physical
health status, developmental matura-
tion, emotional well-being, and social
cohesion3
~
Accordingly, the health-
promotive capacity of an environment
is understood, not simply in terms of
the health effects of separate environ-
mental features (e.g., air quality,
seismic safety, or social climate), but
more broadly as the cumulative impact
of multiple environmental conditions
on occupants’ physical, emotional, and
social well-being, over a specified time
interval)
-~
Another core theme of social
ecological research is that human
health is influenced not only by
environmental circumstances, but also
by a variety of personal attributes,
including genetic heritage, psycho-
logic dispositions, and behavioral
patterns. Social ecological analyses
emphasize the dynamic interplay
between situational and personal
March/April 1996, Vol. 10, No. 4 285