Chronic disease is the leading cause of death and contributes to premature mortality and disability. There is increased awareness across public and private sectors of society for the need to develop and find avenues to support health-promoting lifestyles for the general population. This is of critical importance to those segments of the US population who historically and/or politically have become disenfranchised from our current system of healthcare. Because there is increasing recognition and emphasis on developing healthy lifestyles, it is important that systems ranging from micro to macro within and across segments of society accommodate individual differences in culture, attitudes, and social milieu to leverage mechanisms to impact upon health. It is often too easy to "blame the victim;" to attribute ill health as the result of personal failure (Tesh, 1981). Many approaches to disease management ignore the multiple contextual influences that contribute to health status (McLeroy et al., 1988).
A social ecological perspective takes into account the important connection between individual behavior and the overarching multilayered social system (Martikainen et al., 2002). The ecological perspective proposed by Brofenbrenner (1979) takes into consideration the reciprocal nature of behavior, an individual, and the environment. Specifically, environment influences behavior at the microsystem, mesosystem, exosystem, and macrosystem levels. The microsystem refers to interpersonal influences in specific settings, such as family, social networks, or work groups. The mesosystem refers to interrelationships among 2 or more settings or contexts such as work and family or church and family. The exosystem pertains to influences outside of direct contact but ones in which decisions affect the individual such as unemployment rates. The macrosystem encompasses the social order and cultural beliefs and values that result in norms that influence individual behaviors (micro) and is influenced by the individual behaviors, thus illustrating the reciprocal nature of a social ecological system (Grzywacz & Fuqua, 2000).
As private and public sector systems become more cognizant of the factors relevant to a social ecological approach and continue to implement changes in practices and policies that provide the greatest leverage from a system's perspective, converging methods at multiple levels should result in improved health for the population.
This issue and the next issue of JACM explores a variety of approaches and perspectives at all levels of a social ecological model. Embodied within each, the individual is viewed as part of a reciprocal system that is influenced by multiple tangible and intangible factors. The importance of interpersonal factors is demonstrated by practitioner-patient relationships in several manuscripts. BeLue and colleagues point out the importance of recognizing the heterogeneity of attitudes between doctors and patients about medical decision making relevant to specific treatment options. Clearly, there exist opportunities for practitioners to educate and facilitate patient empowerment. Jia, Santana, and Lubetkin further underscore the importance of provider-patient communication by demonstrating the varying levels of understanding of "risk" among different minority populations. This points to the necessity of assuring linguistically and culturally appropriate education in conveying treatment options and risks in a medical encounter. In a related study, Figaro and colleagues discover that African American patients' preferences of treatment options may link to knowledge as well as trust in the provider-patient relationship (see vol. 28(1)). This is of particular importance for the African American population who, as a race, clearly has experienced a history of abuse by the medical system.
In every patient encounter there is an opportunity for a physician to not only communicate directly about health-promoting behaviors but also to serve as a role model to the patient he/she serves. Cameron, Katch, Anderson, and Furlong introduced into medical school curriculum a pilot study to increase self-awareness of behavioral health practices. They propose that by regularly participating in healthy behaviors, clinicians will be more effective in counseling patients.
Galea and colleagues propose a social ecological approach to leverage elements within microsystems to macrosystems to improve vaccination rates (see vol. 28(1)). These authors illustrate how this approach will have a tremendous impact on poor and marginalized populations. Figaro and Belue underscore the importance of this need and call for strategies to increase influenza vaccination rates in communities of color and other underserved populations (see vol. 28(1)).
Similarly, Margolin and colleagues describe a system-wide approach among 25 communities whose aims are to improve health by collaboration among organizations and social networks. This review provides specific examples that demonstrate the reciprocal nature between the individuals and the various systems of which they are a part that has the potential to have an impact on achieving and maintaining positive health.
It is not only crucial to identify barriers and risks, it is likewise important to understand resources and assets. Thus, providers and leaders of health promotion initiatives can facilitate the leverage of those factors that contribute to positive health status. Ahmed, Fort, Elzey, and Bailey provide an insight about factors that contribute to successful mammography screening among low-income African American women.
Goldfarb and Pietro provide 2 examples of how organizations can sponsor innovative methods that empower patients and their families to enhance traditional methods of treating stroke and dementia.
Monitoring population perceptions of functional health status is an important aspect of developing a health profile and identifying needs of specific populations groups. Cashman and colleagues demonstrate the utility of the SF-12 to assess the needs of low-income, uninsured or underinsured patients at a community health center. This tool, because of its brevity and ease of administration, can be a powerful means to alert providers to current and emerging health issues among the poor (see vol. 28(1)).
Technology can be used to assess and monitor health status to gain "real-time" information about community health needs, enhance community-based collaborations, and provide a comprehensive view of factors that influence health. Three articles illustrate the use of technology; each discusses a specific and unique method but all share a social ecological perspective. Luce, Phillips, Benjamin, and Wasson offer an approach to improve population's health status through a partnership, Chicago's Community Health Alliance, and the implementation of a Web-based data collection and health information system. This microsystem to macrosystem approach can result in directives (surveillance, assessment, planning and policy) that support changes in service delivery at the practice level, and initiate community-wide approaches to improve the management of health-related needs through education and outreach efforts.
The use of Geographic Information Systems is gaining recognition as an analytic tool to enhance our knowledge of environmental factors that influence health. Allacci stresses the importance of identifying neighborhood socioenvironmental patterns that pertain to asthma emergencies that can inform the development of community interventions. She explores different methods to select the most appropriate geographic scales to measure housing conditions, neighborhood physical environment quality, income indicators, and access to healthcare (see vol. 28(1)).
Through telemedicine applications in rural Arizona, Lopez and colleagues demonstrate the accuracy and power of this technology to assist in the care of those who have little access to healthcare services (see vol. 28(1)).
Finally, Mensinger explores sociocultural forces that influence the health of young women in our society and offers systemic strategies that may offset the growing problem of eating disorders among this specific demographic group (see vol. 28(1)).
Collectively, these articles illustrate the ideas, research, and practice of creating change to assure optimal health for all people. This is of particular importance for a society where healthcare remains a privilege. With activities such as those described here, over time, our culture will view health, of all people, as our most important and valued resource.
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