Using an ecological model for health promotion to understand risk for suicidal behaviours in adolescents.
**Disclaimer – this post poses theoretical discussion surrounding suicide risk and may contain triggers**
I’ve chosen this week to examine and ecological model proposed by McLeroy, Bibeau, Steckler, & Glanz (1988) that uses ecological theory to examine health promotion programs. The emergency department in which I practice is both the regional pediatric centre, as well as being on a Form 1 mental health facility. As such, a daily occurrence that we encounter in our childhood and adolescent populations is suicidal behaviours and thoughts. I have chosen to outline why the complex nature of suicide risk can be appropriately examined using an ecological perspective on determinants of health.
Ecological theories of health take into consideration both the individual, their environments, and the effects of overlaying policy (Sallis & Owen, 2015). One of the earliest, modern multiple levels of health theory was proposed by Urie Bronfenbrenner in in 1977, his model described multiple levels of influence on the individual behaviour in the micro-, meso-, exo- and macrosystems and how all of these layers of influence interact with each other (Tannenbaum, 2018).
Tannenbaum, R. [Rachel Tannenbaum]. (2018, January 3). Bronfenbrenner’s ecological theory [Video File].
McLeroy, Bibeau, Steckler, & Glanz propose an ecological perspective of health promotion that uses the theory of Bronfenbrenner as a conceptual base (1988). Their theory examines determinants of health in terms of layers of social and environmental factors that can be targeted for health promotion (McLeroy et al, 1988). This model demonstrates how individual and community behaviour can be affected by and can affect the social environment (McLeroy et al, 1988). The theory proposes these five levels of analysis that affect health behaviours, each level having the potential for health promotion interventions.
· intrapersonal factors – personal characteristics, both physical and social including knowledge, beliefs and skills
· interpersonal process – individual social support and networks including family and friendships
· institutional factors – social institutions (both formal and informal as in schools, workplace or sports teams)
· community factors – relationships amongst institutions and organizations
· public policy – laws and policies existing both locally and nationally
Adapted from McLeroy et al (1988).
The use of an ecological model in examining adolescent suicide is relevant due to the complex nature and difficulty in identifying causal risk factors associated with adolescent suicide behaviours (Perkins & Hartless, 2002). The use of ecological theory allows adolescent suicidal behaviours to be viewed in a multifaceted lens and aid in understanding the complex relationship between risk factors as causal relationships between risk factors and suicidal acts have not been identified (Ayyah-Abdo, 2002).
Using the ecological model proposed by McLeroy et al (1988), risk factors associated with suicide can be viewed through five layers ensuring strategies aimed at prevention to not focus solely on the victim, but on all environmental factors. The first and second layers of analysis include the intra-, and interpersonal interactions. The most significant intrapersonal factors associated with adolescent suicide are hopelessness, substance abuse and depression (Ayyah-Abdo, 2002). McLeroy et al (1988) emphasise the importance of tailoring health promotion not solely on the behaviour of the individual but on the interpersonal factors that affect these behaviours. These interpersonal relationships including family, friends and acquaintances provide social support (McLeroy et al, 1988) and are of vital importance to adolescent development. Family history of suicide, parental psychopathology, loss of important relationships are all risk factors identified in adolescent suicide and almost one third of suicide attempts by adolescents are reported after a perceived loss (Ayyah-Abdo, 2002). Ecological theory of health promotion would therefor suggest focusing interventions on determinants of health that directly affect the mental health of families with children in order to mitigate the risk associated with family dysfunction and a sense of isolation felt by adolescents without adequate support.
The institutional, community and policy levels of analysis associated with ecological theory on health promotion as described by McLeroy et al (1988) can be used to examine suicidal behaviour risk factors on a macro-systems level. Adolescents spend a large amount of time in the school setting and those who feel they are a failure in school are at an increased risk for suicide (Ayyah-Abdo, 2002). Thus, highlighting the importance of school systems being engaged and involved in program decisions around mitigating suicide risk. The community setting can refer not only the physical, but also the psychological sense of community (McLeroy et al, 1988) and to adolescents this would include traditional as well as social media. Although research into social media use and suicide risk has yet to draw many sound conclusions, cyberbullying increases the risk of suicide amongst adolescents at two times the rate of those who are not (Luxton, June, & Fairall, 2012). Creation of public policies related to reducing cyberbullying occurs at the policy level of ecological health promotion theory and could include education programs, national policies and the development of laws aimed at targeting cyberbullying (Luxton et al, 2012). Social media and the internet can be used to preventatively in order to address suicide prevention in health promotion activities aimed at targeting, individuals, schools and by creating larger public health outreach campaigns (Luxton et al, 2012).
Suicide is a complex problem that is becoming more and more prevalent in our society, it is the second leading cause of death from age 14-35 (Statistics Canada, 2017). By using ecological theory to address the complex risk factors associated with suicide healthcare professionals can develop a more complete understanding of this devastating issue. Creation of public policy and programming aimed at all levels of the environment can help to identify adolescents at risk and provide support to adolescents and their families in the hopes of mitigating the risks associated with suicidal behaviours.
References
Ayyash-Abdo, H. (2002). Adolescent Suicide: An ecological approach. Psychology in the Schools, 39(4). doi: 10.1002/pits.10042
Luxton, D., June, J. D., & Fairall, J. M. (2012). Social Media and Suicide: A Public Health Perspective. American Journal of Public Health, 102(2). doi:10.2105/AJPH.2011.300608
McLeory, K., Bibeau, D., Steckler, A., & Glanz, K. (1988). An Ecological Perspective on Health Promotion Programs. Health Education Quarterly 15(4). Retrieved from https://www.cdc.gov/violenceprevention/overview/social- ecologicalmodel.htmlhttps://www.researchgate.net/profile/Kenneth_Mcleroy/publication/ 20088489_An_Ecology_Perspective_on_Health_Promotion_Programs/links/0d1c84f972 a1e3f12d000000/An-Ecology-Perspective-on-Health-Promotion-Programs.pdf
Perkins, D. F., & Hartless, G. (2002). An Ecological Risk-Factor Examination of Suicide Ideation and Behavior of Adolescents. Journal of Adolescent Research, 17(1).
Sallis, J. F., & Owen, N. (2015). Ecological Models of Health Behaviour. In K. Glanz, B. Rimer, & K. Viswanath (Eds.), Health Behaviour: Theory, Research, and Practice (pp. 43-64). Retrieved from https://books.google.ca/books?id=0j4LCgAAQBAJ&printsec=frontcover&source=gbs_g e_summary_r&cad=0#v=onepage&q&f=false
Statistics Canada. (2017). Suicide Rates: An overview. Retrieved from https://www150.statcan.gc.ca/n1/pub/82-624-x/2012001/article/11696-eng.htm
Tannenbaum, R. [Rachel Tannenbaum]. (2018, January 3). Bronfenbrenner’s ecological theory [Video File]. Retrieved from https://www.youtube.com/watch?v=HV4E05BnoI8
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