Multi-level Models of Care
Multi-level models in health care have been a major focus in recent years. Health is so broad with so many influencing factors, it is challenging to address health issues without having an all-encompassing approach. Multi-level interventions allow us to evaluate and intervene at every level that may affect ones health instead of focusing on one single determinant of health. (Brown, n.d.-b). I will introduce the Social-Ecological Model (SEM), consider a cancer patient's journey, and then apply the SEM to the cancer patient's journey. I will then discuss an example from a peer-reviewed journal of how the SEM was applied in their specific situation.
Social-Ecological Model
When researching multilevel models in health, the Social-Ecological Model stood out as very inclusive and thorough – considering all aspects of the influences on a person. It is a framework utilized to help understand the multifaceted levels within a society, and how people interact with their environment and within a social system. (Brown, n.d.-a). According to the Lumen Learning website in Chapter 3: Social Ecological Model, the following is a description of each of the levels in the Social Ecological Model:
Individual: Typically includes biological and personal factors. A person’s knowledge about disease, and consideration how susceptible to disease they are.
Interpersonal: Close relationships with their partner/family/friends. How relationships with others may have affected a person’s consideration of health. I.e. how they were raised and if their parents talked to them about health.
Organizational: Schools, workplaces and neighborhoods and their influence on health.
Community: How all of the organizations in a community come together. Do the services in the community complement each other, and work together to help patients.
Public Policy: Societal impacts (i.e. social and cultural norms. How the government and their policies affects the whole population. (Brown, n.d.-b).
Cancer Patient’s Journey
A person who develops cancer has a journey that started with prevention measures and will end with either recovery or end of life care. There are many influencing factors along the way that can change each person’s experience with cancer. Unfortunately, vulnerable populations are at higher risk of having a delay in starting treatments for cancer. This can have a great effect on their prognosis and overall experience. (Frosch et al., 2023) It is important to consider all of the determinants of health that may influence a cancer patient’s journey along the way.
Applying the Social-Ecological Model to a Cancer Patient’s Journey
Working in a PET/CT department, I mainly see cancer (or potential cancer) patients at different stages of their journey. Some are still in the investigation stage, others are on surveillance monitoring after completing treatment. Whatever stage they are in, they always talk about their journey and the challenges they have faced, and still face. I chose to apply a cancer patient to the Social-Ecological Model, looking at how the following levels have affected their health journey: Individual, Interpersonal, Organizational, Community, and Public Policy. (Early, 2016).
On an individual level, how a patient ended up developing cancer is often unknown. Most of us are aware of factors that may increase our risk of getting cancer (smoking, toxins, genetics and extensive sun exposure, to name a few). Some of these are within our control, but of course things like genetics are not. However, the more aware we are, the more proactive we can be. Therefore, some patients that have a known family history of certain cancers can have earlier, more thorough monitoring to ensure that if they also end up with such cancer, it would be caught earlier and they would have a better prognosis. Similarly, if patients are more aware of the things that increase the overall risk of cancer, they may become better able to avoid them.
Interpersonal factors for a cancer patient would include the way health was perceived within their closest relationships. For example, if health was something the family considered important while they were growing up, or if their partners and children make health a priority. Many people that were surrounded by smokers during their lifetime are likely at a higher risk of smoking themselves, for example. Also, if talking about health issues was taboo (i.e. families didn’t openly discuss bowel changes or skin issues) then a person may be less likely to seek professional advice whenever these things occurred.
Organizational considerations for a cancer patient could refer back to their schooling and educational levels. If they attended school, was health one of the subjects that was taught? Were they aware of health issues, and how they may present? Are they aware that early intervention is important? Similarly, their workplace may encourage workers to take care of their health, and provide time away to see doctors or do other health promoting activities. Alternatively, their workplace may provide extra breaks for those that smoke, which could encourage workers to engage in activities that increase cancer risks.
At a community level, a cancer patient may be a part of a community that supports health education, with events and posters for the public to avail of. They may come together to offer surveillance clinics for those without other means to do so, for example PAP clinics. They may offer FIT testing for colon cancer screening via mail or provide information sessions on various health topics. Theses supportive measures can alter ones journey before or during their cancer journey.
Finally, the impact of public policy is huge. The government’s choices regarding where they allocate health care resources can play a large role for a cancer patient. For example, once a patient knows there is a chance they have cancer, they often have to wait extended periods of time for the diagnostic testing to be completed. So even those who are very proactive and want to quickly treat any health issue they are experiencing, unfortunately they may have to wait months for the testing to be completed before their doctors are able to actually start the treatment process. This is a major factor that the patients I see struggle with. The lack of resources stems back to government policies and this unfortunately has a large effect on a cancer patient’s journey.
Image from: (Early, 2016).
Evidence from a Peer-reviewed Journal
In the article “Applying the Social Ecological Model to Evaluate a Demonstration Colorectal Cancer Screening Program in Louisiana” in the Journal of Health Care for the Poor and Underserved, we see a great example of the Social Ecological Model (SEM) in action. Nuss et al. recognized that colorectal cancer screening is one of the most underused screening tools and noted that noncompliance was more common in racial/ethnic minorities, those of a lower socioeconomic status, and those without medical insurance. They set out to increase access to these screening tests to populations with low incomes and that do not have medical insurance. The SEM was selected to support this initiative to ensure a multilevel approach was taken. At the individual level, they selected a screening test that was easy for each person to comply with. At an interpersonal level, they utilized a patient navigator to assist each person however they may need, to ensure they knew how to use the screening test and to follow up with them. At an organizational level, they utilized a new referral system, as well as reduced barriers by providing the screening tool kits necessary. At the community level, multiple groups supported the initiative, both with professional recommendations and support, as well as funding. As you can tell, a multi-level approach using the SEM framework was used in this project, and their outcome was positive – their return rate was 66%, which was up from about 50% prior to this initiative. (Nuss et al., 2012).
Conclusion
The Social-Ecological Model is a great way to consider the many contributing factors to a patient’s health and their whole journey. This is an effective model to encompass the whole patient and to consider the multifaceted levels that influence health and individual health journeys. Nuss et al. demonstrated how this model can be used for a colorectal cancer screening initiative that successfully increased compliance.
References
Brown, A. (n.d.-a). 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/
Brown, A. (n.d.-b). Models and mechanisms of Public Health. Multilevel Interventions are for Behavior Change | Models and Mechanisms of Public Health. https://courses.lumenlearning.com/suny-buffalo-environmentalhealth/chapter/multilevel-interventions-are-for-behavior-change/#:~:text=Multilevel%20interventions%20target%20the%20causes,a%20widespread%20public%20health%20issue.
Early, J. (2016). Health is more than healthcare: It’s time for a social ecological approach. Journal of Nursing and Health Studies, 01(01). https://doi.org/10.21767/2574-2825.100000e2
Figure 1 conceptual framework using the Social Ecological Model. Research Gate. (n.d.). https://www.researchgate.net/figure/The-Social-Ecological-Model-provides-a-framework-for-considering-what-and-how-to-evaluate_fig1_312507167
Frosch, Z. A., Hasler, J., Handorf, E., DuBois, T., Bleicher, R. J., Edelman, M. J., Geynisman, D. M., Hall, M. J., Fang, C. Y., & Lynch, S. M. (2023). Development of a multilevel model to identify patients at risk for delay in starting cancer treatment. JAMA Network Open, 6(8). https://doi.org/10.1001/jamanetworkopen.2023.28712
Nuss, H. J., Williams, D. L., Hayden, J., & Huard, C. R. (2012). Applying the social ecological model to evaluate a demonstration colorectal cancer screening program in Louisiana. Journal of Health Care for the Poor and Underserved, 23(3), 1026–1035. https://doi.org/10.1353/hpu.2012.0120
Working across the cancer patient journey. Cancer Research UK. (n.d.). https://www.convergencesciencecentre.ac.uk/research/interventional-science/working-across-the-cancer-patient-journey
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