The Ecological Approach to Public Health Root Causes

Traditional approaches to public health and the health initiative have been flawed. A modern body of research in public health has been successful in demonstrating why the novel ecological approach to health and wellness is necessary to encourage wellness and foster permanent lifestyle and behavioral modification. In addition, the ecological approach is important in order to develop an understanding of root causes of inequities and discriminations, which lead to unhealthy behaviors or conditions in which individuals struggle to prosper. A traditional definition of the ecological perspective in public health implies reciprocal causation between the individual and the environment from micro- to macrolevels [1] for example, the host-agent-environment model of ecology in public health. The ecological model, as described by Minkler [2], is composed of intra- and inter-personal factors, community and organizational factors, public policies which are interdependent levels of analysis to be considered. This conception is much more appropriate for a public health perspective. Individual’s developmental histories and their social support systems; the organizational structures and process that can positively or negatively affect health behavior; community networks and power structures; and both the content of our public policies and the role of participation, advocacy, and other process in their formation all are key component of a broad ecological perspective in health.

Public health advocates have often argued that public health scholars should address the ‘causes of the causes’ while also addressing the ‘root of the causes’. Literature exploring racial injustice from a public health perspective [3,4] echo this argument. Using the socio-cultural conditions of the St. Louis suburb as a case study, should we health professionals search upstream for solely the root of the causes, ignoring all subsequent causes, failing to address downstream needs brought on by the Root cause, we would not find a tangible object upon which to institute change – rather, we would face an ideology [racism] as the target for change. Ferguson came to be deeply segregated (predominantly black), deeply impoverished, and undereducated by way of racist policies of the federal, state, and local governments. The end result was “de facto” segregation. The belief that segregation is the result of accident, income difference, private discrimination, or the unintended result of race-neutral policy – is mythical. Rather it is deliberate segregation, brought on by policy [3,4]. Sadly, there is nothing unique about racial history in Ferguson – many municipalities in the US operated) in the same manner. But if public health officials and professionals aimed solely at defeating the ideal of racism (upstream approach) in effort to improve the health and wellbeing of communities under the effect of institutionalized racism, they would be missing important opportunities to improve present-day conditions for the effected populations along the way (using downstream approaches). Years and decades will pass before measurable improvements to racially divided communities could be felt, yet the citizens living under such present-day conditions could still feel the benefit of microlevel improvements (e.g. installing playgrounds in a segregated community to encourage physical activity; passing legislation to ban the sale of liquor and firearms in living communities; institute re-training programs for police forces, et cetera). I recognize that simply building parks, sidewalks, and cosmetic changes to low socio-economic and minority neighborhoods are superficial improvements, fails to illuminate the macro-problems. It is, in fact, why health professionals must continue to swim upstream, discover and address root causes [5], so we may attack the problem [ideological racism and the tangible consequences] from both sides.

The relationships between social factors and health are easily identified, but not simply explained. Half of all deaths in the United States (US) can be attributed to behavior. Naturally, health behaviors are shape by social factors – income, education, employment [5]. It is accepted that potentially avoidable factors associated with lower educational status account for half of US adult deaths per year. This indicates a connection between social factors and health. Some connections to social factors and health are more direct (e.g. lead ingestion in substandard housing, pollutants in less affluent neighborhoods, et cetera). Additional socio-economic connections include exposure to violence in low socio-economic neighborhoods increase the likelihood that youth will perpetuate violence, exposure to alcoholism in youth increases likelihood of misuse of alcohol in adulthood [4]. Some connections are less direct (e.g. poor neighborhoods have fewer recreational facilities potentially attributing to the adoption of a sedentary lifestyle of neighborhood youth; chronic childhood stress leading to drug use, and the domino effect thereafter).

There are noteworthy challenges to studying upstream socioeconomic and other factors’ effect on health. For instance, these conditions cannot be observed through traditional experimentation. Additionally, there is a long lag time for any health benefits to be expressed [5]. Because of these reasons, identifying long-term successful interventions to causes and root causes has been challenging. I believe one mid-stream intervention for promoting and achieving goals in public health is to address the disparity in education among disenfranchised populations. Education is a strong predictor of health, so reducing K-12 school dropouts should be a priority for health professionals – most notably in minority groups who tend to be less healthy and experience a higher dropout rate. Freudenberg and Ruglis [6] identified several healthrelated reasons for dropouts: pregnancy, psychological, emotional, and behavioral problems, and mental illness. A more developed education leads to higher paying jobs. More money means house in safer neighborhoods, healthier food, better medical care and health insurance. Achieving a more developed education could save more lives than advances in medicine [6]. Many interventions aimed at addressing health related dropouts have been limitedly successful. I echo sentiments advocating for increased focus on reducing dropout rates – the expectation being a measurably positive effect on health and wellness.

None.

Author declares no conflict interest.

1. McLeroy KR, Bibeau D, Steckler A, Glanz K (1988) An ecological perspective on health promotion programs. Health Educ Q 15(4): 351-377.
2. Minkler M (1999) Personal responsibility for health? A review of the arguments and the evidence at century’s end. Health Educ Behav 26(1): 121-141.
3. Rothstein R (2015) The Story behind Ferguson. Educational Leadership 72(6): 28-33.
4. Woods LL, Shaw Ridley M, Woods CA (2014) Can health equity coexist with housing inequalities? A contemporary issue in historical context. Health Promot Pract 15(4): 476-482.
5. Braveman P, Gottlieb L (2014) The social determinants of health: it's time to consider the causes of the causes. Public Health Rep 129(Suppl 2): 19-31.
6. Freudenberg N, Ruglis J (2007) Reframing School Dropout as a Public Health Issue. Prev Chronic Dis 4(4): A107.