Integrating the Ecological Approach in Disease Prevention and Health Promotion Programs for Older Adults

Context

In Canada, health care services come under provincial jurisdiction. Most provincial governments, including Québec, have assigned the decision making process (planning, resource management, and budget allocation) to authorities working in regional establishments. Although the regionalization process had been underway for some time in Québec, an additional reform occurred in 2004 wherein service delivery was restructured around local service networks. In each region, agencies are responsible for coordinating and setting up local services/programs on their territory. At the local level, the Centres de santé et des services sociaux (CSSS; Local Health and Social Services Centers) now act as the headquarters for this new mode of service/program delivery and have the mandate of organizing, in collaboration with partners, the delivery of health and social services on their territory to meet population needs (Ministère de la santé et des services sociaux, 2004). In public health, this method implies that regional agencies, through their Directions de santé publique (DSP; Public Health Departments), organize and carry out public health functions (e.g., disease prevention, health promotion, protection) and implement the regional public health action plan, in compliance with the Public Health Act and the Quebec National Health Program (Ministère de la santé et des services sociaux, 2003) taking into account the unique characteristics of the population in their territory. The CSSSs are now being given the responsibility of delivering “frontline” public health services to local populations: Actions that are aimed at health promotion, disease prevention, and health protection in accordance with the regional and local public health action plans (Ministère de la santé et des services sociaux, 2004). It should be recognized that as a result of this hierarchical organization of service delivery, the DSP does not directly deliver services to the population. Rather, services to the population are offered by the CSSSs.

Design and Case Selection

We adopted a case study design using the DSP and its DPHP programming for older adults as the unit of analysis. Programming was conceived as the DSP’s entire ensemble of DPHP initiatives (programs, interventions, etc.), offered to achieve objectives related to the health of older adults. Two cases (referred to as DSP A & B) representing contrasting profiles in regard to the degree of integration of the ecological approach in DPHP programming for older adults (i.e., extensive vs. limited integration as shown by number and types of strategies deployed and of intervention settings as well as the number of initiatives) were identified. Data collected during a previous study examining DPHP programming in DSPs (Richard et al., 2008) were used to identify an initial set of contrasting DSPs. Other criteria were also taken into account. That is, to limit sources of variability, only DSPs whose headquarters were located in urban or peri-urban environments and that were servicing populations similar in size and proportion of older adults were included. Finally, for practical purposes, organizations located more than 200 km from Montreal were excluded as were two organizations that had recently participated in another study by our team.

DSP A (extensive integration of the ecological approach) serviced a population of 302,161 residents which included 15% older adults (age ≥ 65years). Its territorial catchment area was about 10,000 km² and included urban, peri-urban, and rural subareas. DSP B (limited integration of the ecological approach) serviced a population of 376,845 residents which included 14% older adults. The catchment area was somewhat smaller at 246 km² and characterized by urban subareas with predominantly suburban-type housing.

Procedure and Measures

Once agreement to participate had been received from the directors of DSPs, the profile of each organization in regard to integration of the ecological dimension into DPHP programming for older adults was updated. That is, the list of programming initiatives identified in the previous study (Richard et al., 2008) was reviewed and a detailed description of new and modified initiatives was drawn up to enumerate intervention strategies and settings. In line with Richard et al. (2008), an intervention strategy refers to the intervention pathway from where the intervention initiative is instigated to where it reaches individuals whose health we wish to promote. The analysis chart includes five targets: the individual client and their interpersonal, organizational, community, and political environments. For example, a healthy nutrition initiative may include two strategies, one involving action on diabetic seniors (individual target) and another involving action on their spouses (interpersonal target). The intervention setting is defined as the context or social system in which individuals ultimately targeted by the DPHP strategy are reached. Four categories of settings are used: organizations, community, society (e.g., province), and supranational systems (e.g., European Economic Community). To continue with our example, the healthy nutrition initiative may reach individuals when they visit their physician (health organization setting); alternatively, individuals might be reached through a community media campaign (community setting).

Data related to environmental, organizational, and professional factors hypothesized to be associated with the degree of integration of the ecological approach (see Table 1) were collected by means of semidirected interviews with professionals identified as resource persons (n = 9) for specific initiatives in each DSP. Interviews lasting about 90 min were also conducted with members of middle and upper management (n = 5) in both DSPs. Archival data were examined and included action plans and portraits of the health of local populations. Data were collected in 2006; shorter follow-up interviews were carried out in 2007. The Health Sciences Human Research Ethics Committee of the Université de Montréal approved the project.

Analysis

Information pertaining to the updated list of programming initiatives was reviewed by two analysts (MT, LR) to identify intervention settings and strategies. All differences in coding were resolved by consensus.

Data from interviews and archival documents were content analyzed. The first step involved coding of interview materials in terms of themes falling into each category of contextual factors derived from the Scheirer model (see Table 1) by one of the team members (MT). Coding was then thoroughly reviewed by a second team member (LR) and differences were resolved by consensus. Next, summary statements were produced for all themes identified and used to establish a portrait of each DSP. The final step involved examining the two portraits and writing a comparative analysis. Toward this end, the analyst responsible for these last two steps (LR) built a chain of evidence which involved careful specification of each step in the reasoning process and inclusion of detailed references to the data set at each step. A third member (MEL) validated the analysis. For penultimate validation purposes, results and interpretation were presented to and discussed with interview respondents at each DSP during two separate, 75-min consensus meetings.

Degree of Integration of the Ecological Approach in Contrasting DSPs

In line with the profile established a few years prior (Richard et al., 2008), the analysis carried out on the updated initiatives allowed for corroboration of contrasting profiles and recognition of some commonalities. In both sites, the programming initiatives addressed a variety of health issues with physical health issues being the focus most often (see Table 2). As shown in Table 3 though, a greater number of programming initiatives was implemented in DSP A (12 vs. 9) and overall initiatives encompassing a much greater number of intervention strategies (23 vs. 11). Furthermore, a detailed analysis revealed a marked difference in terms of the diversity of these strategies. Only two types of strategies were observed in DSP B, namely actions on individual and organizational targets. By contrast, a more diversified profile emerged in DSP A where six different types of strategies were identified, including various networking strategies. Such networking strategies, which were conspicuously absent from DSP B’s programming and which consist of getting actors to work collaboratively on a health issue of common concern, is very much in line with the tenets of the health promotion movement and the implementation of innovative and more ecological community-based approaches (Stith et al., 2006; Zakocs & Edwards, 2006). With regard to intervention settings, the analysis showed seven different types of settings in both DSPs (data not presented). Health organizations of various types (hospitals, clinics and physicians’ offices, long-term care facilities, and local public health organizations) were frequently found in DSPs A and B, but DSP A clearly showed a very distinct profile with higher frequencies of other types of settings, including the community setting. Community settings are, of course, of critical relevance for the implementation of large-scale ecological programs. Overall, these analyses support the notion that the two DSPs were indeed contrasting organizations with DSP A showing extensive integration of the ecological approach whereas DSP B showed very limited integration.

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Table 2.

Health Issues Targeted Through Programming Initiatives

	DSP
Issue	A—Extensive integration of ecological approach	B—Limited integration of ecological approach
Nutrition	X	X
Oral health/dental health	X	X
Medications	X	X
Falls	X	X
Screening—disabilities	X
Multithemes	X
Immunization	X	X
Screening—cancer	X	X
Physical activity	X	X
Abuse-violence-neglect	X
Bereavement		X

Note: DSP = Directions de santé publique.

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Table 3.

Ecological Analysis of Programming Across Contrasting Organizations

	DSP
	A—Extensive integration of ecological approach	B—Limited integration of ecological approach
Total number of initiatives in overall programming	12	9
Total number of intervention strategies across programming initiatives	23	11
Number of distinct interventions strategies identified across programming initiatives	6 a	2 b
Number of intervention strategies involving networking among targets	5	0
Number of intervention strategies involving a setting other than health care organizations	18 c	5 c
Number of intervention strategies involving a community setting	12	2

a.

Action on an individual target (n = 8 programming initiatives); Action on an interpersonal target (n = 1 programming initiative); Action on an organizational target (n = 8 programming initiatives); Networking among individual targets (n = 1 programming initiative); Networking among organizational targets (n = 3 programming initiatives); Networking among organizational and political targets (n = 1 programming initiative).

b.

Action on an individual target (n = 2 programming initiatives); Action on an organizational target (n = 9 programming initiatives).

c.

Community-based organizations, groups and associations, the community.

Contextual Factors Associated With Implementation of DPHP Programming Initiatives

Organizational Factors

Planning of Programming Initiatives

Professional Factors

At DSP A, the public health professionals directly involved in DPHP for older adults had vast experience within the DSP (all more than 10 years), sometimes coupled with other experiences within the public health system. The fields in which they were originally trained were diverse (e.g., gerontology, kinesiology) and two people had postgraduate degrees. At DSP B, a few people also had had involvement in older adult dossiers. In total, however, the number of years of experience was lower than at DSP A. The background disciplines were varied at the postgraduate level.

Informants were questioned as to their personal definition of the ecological approach (a definition was classified as “correct” when the response included references to varied intervention settings, targets, and/or intervention strategies). In DSP A, three respondents provided a correct definition, whereas only one person at DSP B responded correctly (at DSP A, a fourth informant was not asked about his or her definition; however, in the analysis, all of his or her remarks reflected an excellent knowledge of the approach). As for perceptions about the ecological approach, more positive elements (especially in connection with relevance and effectiveness) than negative (especially in relation to the complexity of the approach, its long-term impact, and the costs involved) were observed at both sites.

Comparative Analysis

The between-case analysis revealed two groups of factors distinguishing the two DSPs. Human and financial resources constituted the first group. The professionals at DSP A had been working on older adult issues for much longer than those at DSP B; they also seemed more familiar with the ecological approach. The validation stage provided confirmation of the importance of human resources with the stability of staff in DSP A and, in contrast, the turnover of staff in DSP B. In addition, the budgetary resources appeared significant such as the presence of a strategy for maximizing budgets through collaboration with another department that organizes services which clearly emerged as a key factor in DSP A. Finally, the establishment of close links between the team at DSP A and its partners in the university milieu dedicated to the study of aging appeared to play a crucial role in allowing for the integration of the ecological approach, a finding that was strongly endorsed during the consensus meetings. Aside from these differences, the analysis revealed many commonalities in terms of factors of influences. Table 4 outlines common factors and key differences across the two DSPs.

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Table 4.

Commonalities and Key Differences in Factors Influencing the Integration of the Ecological Approach in DSP A (Extensive Integration) and DSP B (Limited Integration)

Category of factors of influence	Commonalities	Key differences
Environmental	Strong partnership with community partners involved in DPHP for older adults	None
	Lack of resources among community partners
Organizational	No DSP team devoted exclusively to the older clientele	DSP A has established a formal partnership with another department devoted to older adults who are losing their independence ; such partnership brings a higher level of resources
	The older adult clientele not given priority in the National Health Program	Link with university with specialization in older adults in DSP A
	Priorities affected by ease of measurement of individually oriented strategies
	Work procedures (focus on issues, formal consultation with partners, management and connection to the regional action plan)
	CSSSs as major partners in the DPHP planning process
	Lack of resources devoted to DPHP for older adults
	Relationships with another department devoted to older adults who are losing their independence
	Bias toward youth programs in public health
	Support for older adult programming by management and colleagues
	Context created by the health care reform
Professional	Strong support toward the ecological approach despite acknowledged challenges	DSP A professionals have more training and years of experience in older adults
		DSP A professionals show a higher level of knowledge of the ecological approach

Note: DSP = Directions de santé publique; DPHP = disease prevention and health promotion; CSSS = Centres de santé et des services sociaux.

Shared Factors Impeding Implementation of the Ecological Approach

Respondents at both sites elaborated at length on a series of macro-contextual elements they identified as major influence on their limited capacity to adopt innovative DPHP approaches for their older adult clientele. Of initial interest is the lack of data supporting the effectiveness of specific DPHP interventions for older adults, as a factor likely to delay inclusion of ecological programming initiatives. The heavy reliance on efficacy as a criterion for choosing an intervention resulted in a greater focus on individual initiatives which were often clinical and for which evaluation findings are more readily available. In summarizing data on effectiveness of DPHP interventions, Anderson et al. (2005) wrote that, “Public health is still short of the material base for comprehensive evidence-based decision-making” (p. 228). This would be the case particularly for interventions concerning emerging issues, implemented more widely, involving socioenvironmental determinants and where complex processes of social changes are at work. Elaborating on this, Berkeley and Springett (2006b) stress the absence of consensus on appropriate evaluation frameworks to assess the impact of complex social programs like health promotion programs. These authors suggest that the armamentarium used in public health, which is still based mainly on the biomedical model, is not well suited to the more social approach of health promotion.

Closely associated to the evidence-based rhetoric are a series of political barriers identified by the respondents as constraining the adoption of innovative DPHP approaches. In this respect, consistent with the analyses of the policy directions being taken by liberal political economies such as Canada (Raphael, Curry-Stevens, & Bryant, 2008), lack of support for long-term intervention and resistance to political action, notably on structural determinants, was reported. Respondents indeed stressed the expectations of management in terms of quantifiable and short-term results, these being at the heart of evaluative practices brought by successive health care reforms, largely triggered by a context of public funding crisis. The detrimental effect of such practices on health promotion initiatives in United Kingdom, yet in the context of governmental policy positions supporting action on health determinants, have been exposed by Berkeley and Springett (2006a, 2006b). Originating from a province that has a reputation for being a leader in innovative public health approaches, these results are reminiscent of the British experience and clearly establish a relationship between political macro dimensions and the prioritization of clinical, individual preventive approaches to the detriment of programs targeting the environment.

Finally, another potentially important political barrier emerged in that respondents often referred to the lack of room given to the older adult clientele in ministerial orientations, more specifically in the Québec National Health Program, where this clientele appears to be considered as a lower priority in comparison with other population subgroups. With the exception of abuse-violence-neglect, the objectives devoted to older adults in the program were all related to physical health issues, giving credence to Bennett and Flaherty-Robb’s (2003) impression of a possibly truncated vision of the determinants of quality of life among older adults. The possibility that this situation is a reflection of ageism was not retained during consensus validation. The issue of ageism in public health has already been raised (Ory et al., 2003; Runciman et al., 2006). This study results show that this is a sensitive issue which would need to be investigated from a research perspective.

Factors Associated With Greater Integration of the Ecological Approach

Despite these constraints, one of the organizations studied had begun to implement programming initiatives that included significant diversity in regard to intervention settings and strategies. Resources and partnerships emerged as two factors contributing to success. In regard to resources, the results are certainly consistent with previous studies that show their marked influence both on the development of DPHP programming initiatives (Stith et al., 2006) and on implementation of ecological programming initiatives (Richard et al., 2004). In addition, the favorable impact of establishing partnerships with research and teaching milieus is certainly in line with numerous studies that have demonstrated the key role played by involvement of professionals with organizations and players outside their organization (Richard et al., 2002; Riley et al., 2001). For several decades, organizational research has shown a link between organizational innovation and maintaining contacts and collaboration with the external environment (Aiken & Hage, 1971; Monge, Cozzens, & Contractor, 1992). Two mechanisms could certainly be at play here: the links and exchanges that ensure the influx of innovative programming approaches and practices that provide solutions to issues arising from implementing a demanding and complex programming approach.

Limitations and Future Research

Despite its noteworthy features, this study has some limitations. First, although the use of a conceptual framework orientating the research toward a comprehensive set of factors presents an obvious advantage in terms of interpreting evidence, it also limits the depth of key elements emerging from interviews. A more focused investigation of the question of partnerships with the external environment would, for example, allow for the emergence of information regarding mechanisms favoring the establishment of such partnerships. Such an approach would also make possible an in-depth analysis of the interactions between the environmental, organizational, and professional factors of the Scheirer model, thus potentially allowing for the identification of additional dynamics. Second, the retrospective character of the analysis may have complicated the task for respondents. Longitudinal studies examining the capacity of teams to implement ecological programming initiatives in a context of change are promising. Third, although a case study design certainly allows for a rich, in-depth investigation of DPHP programming, it shows a limited potential in terms of generalizing results to other organizations in Québec or elsewhere. Replication with a larger number of cases and extensions to new organizational and geographical contexts are needed. Finally, it would be advantageous to integrate managers and interventionists more extensively into the research team. This participatory action research strategy is more attuned with the “ecological spirit” (Ryerson Espino & Trickett, 2008) and would maximize the potential for initiating a change agenda aimed at political and organizational environments that are more receptive to health promotion approaches.

Conclusion and Recommendations

Despite its limitations, this study identified factors influencing the integration of the ecological approach in DPHP program planning for older adults and thus provides orientation for policy makers and practitioners interested in implementing this approach. Including a more comprehensive set of priorities aimed at older adults within ministerial orientations and programming is certainly one of the first objectives to pursue. A second priority would be to insure that DSP team stability and budgetary resources required for implementing complex approaches are present. In this respect, establishing teams of professionals devoted to the older adult clientele and offering ongoing training on the ecological approach are promising strategies. Another important action lever involves developing partnerships across programming teams and external organizations including university milieus.