Running head: SOCIAL ECOLOGY THEORY: ORAL HEALTH

Social Ecology Theory in Oral Health Maureen M. Harrington University of the Pacific

SOCIAL ECOLOGY THEORY: ORAL HEALTH

Theoretical frameworks provide researchers guidance in making sense of data and the world. Identifying a theory that relates to ones research interests supports the use of established pathways upon which to build research. I researched a framework that has been frequently used in my area of research and practice: Urie Bronfenbrenners social ecology theory and its second iteration, bioecological or the Process-Person-Context-Time theory. Bronfenbrenner, an influential developmental psychologist, produced his critical publication in 1979 called The Ecology of Human Development which defined social ecology as the study of human development, the environment and the evolving interaction between the two. The revised theory is called Process-Person-Context-Time or bioecological systems theory and encompasses a lifespan approach. Bronfenbrenner collaborated with several researchers, including Stephen J. Ceci, Gary W. Evans and Pamela Morris, on this second iteration of social ecology theory (Bronfenbrenner, 2005; Bronfenbrenner & Ceci 1994; Bronfenbrenner & Evans, 2000; Bronfenbrenner & Morris, 2006). Bronfenbrenner suggests that human behavior occurs within multiple systems: microsystem, mesosystem, exosystem, macrosystem, chronosystem. The microsystem includes the institutions and groups that most immediately and directly impact an individual, such as family, school, religious institutions, neighborhood, and peers. The mesosystem refers to the connections between microsystems. The exosystem refers to links between a social setting in which the individual does not have an active role and the individual's immediate context. The macrosystem is the culture in which individual lives including socioeconomic status and ethnicity. The final component is the chronosystem is patterning of environmental events and transitions over the life course, as well as sociohistorical circumstances (Bronfenbrenner, 1994).

SOCIAL ECOLOGY THEORY: ORAL HEALTH

My interest in social ecology/bioecology theory is based in the multiple levels of systems and potential methodologies involved as well as the evolution of theory. The social ecology/bioecological theory has two phases, which indicates the original theory was not a stagnant or finished product but continued to evolve and be shaped by new influences, information and ideas. Bronfenbrenner participated in a self-directed critical feedback loop and subsequently advocated dynamic research (Tudge, Mokrova, Hatfield, Karnik, 2009; SimonsMorton, McLeroy, & Wendel, 2012). This type of dynamic processes is the basis of my practice and philosophy to research. History Bronfenbrenners first approach to social ecology theory appears to be the most widely used and cited in scientific literature. The theory originally focused on children and families. The value of the theory permeated to other sciences and disciplines, including public health. The social ecological model looks at multiple levels of influence on specific health behaviors. In the public health arena, the systems are frequently defined as levels. These levels include intrapersonal (individual's knowledge, demographics, attitudes, values, skills, behavior, selfconcept, self-esteem), interpersonal (social networks, social supports, families, work groups, peers, friends, neighbors), organizational (norms, incentives, organizational culture, management styles, organizational structure, communication networks), community (community resources, neighborhood organizations, folk practices, non-profit organizations, informal and formal leadership practices), and public policy level (legislation, policies, taxes, regulatory agencies, laws) (McLearan& Hawe, 2005; Quinn, Thompson & Ott, 2005; Glan, Rimer & Viswanath, 2008;

SOCIAL ECOLOGY THEORY: ORAL HEALTH

The second version of the Bronfenbrenner theory, Process-Person-Context-Time (PPCT) or the bioecological theory is described in the following manner. The first P in the theory is processes which are fundamental to human development. The second P is person which establishes the importance of biological and genetic components of the individual. Personal characteristics of importance are divided into three types: demand, resource, and force characteristics. Demand characteristics act as an immediate stimulus to another person. These characteristics include age, gender, skin color, and physical appearance. Resource characteristics include mental and emotional resources, such as past experiences, skills, and intelligence, and include social and material resources (access to good food, housing, caring parents, and educational opportunities appropriate to the needs of the particular society). Force characteristics address temperament, motivation, and persistence. The C or context of the theory, or environment, involves four of the five interrelated systems of the original theory: the microsystem, the mesosystem, the exosystem, and the macrosystem. The T element of the PPCT model is time. Micro-time (what is occurring during the course of some specific activity or interaction), meso-time (the extent to which activities and interactions occur with some consistency in the developing persons environment), and macro-time (the chronosystem) (Bronfenbrenner & Morris, 1998). Social Ecology in Health and Education Although social ecology was developed as a way of viewing child development, I discuss social ecology theory as a tool to view health, health promotion and health behaviors. Public healths close alignment with social ecology theory began in the 1950s with English and American studies on the effects of tobacco use on cancer rates and mortality within a population of physicians (Doll & Hill, 1954).

SOCIAL ECOLOGY THEORY: ORAL HEALTH

As noted in many foundational public health textbooks, personal health behavior is influenced not only by individuals cognitions but also by their relationships with others, their affiliation with organizations, their location within communities, the politics of their time, and their connections with their culture (Simons-Morton, McLeroy, & Wendel, 2012; Bensley, & Brookins-Fisher, 2009). However, public health renamed the systems to individual, organizational, community and policy as noted by the US Centers for Disease Control and Prevention in Figure 1. Figure 1: Social Ecological Model from the US Centers for Disease Control and Prevention

The social ecology theory has been used extensively in education. There is a large body of literature in the areas of child development, student and teacher performance in schools, mental health, counseling, special education, student self-determination, teacher training and curriculum, bullying prevention and family engagement with schools (Bronfenbrenner & Morris, 1998, 2006). Use in Health and Oral Health

SOCIAL ECOLOGY THEORY: ORAL HEALTH

As was mentioned previously, the theory has been adopted and used widely in many other disciplines. Of particular importance to me is the theorys use in health education, health promotion and public health. The theory has been used as an essential foundation of public health planning and program development. In addition, social ecology/bioecological theory is the framework for curricula at major schools of public health, the basis of core competencies in national public health certification examinations, and foundation of several federal health agencies, like the National Institute of Health (NIH). However, the theory is used only sporadically in dental education. In most instances, the theory is integrated as a public health philosophy into dental education curriculum by providing a Master of Public Health (MPH) degree alongside the Doctor of Dental Surgery (DDS) degree. Yet, the social ecology/bioecology framework appears to be moving into the realm of dental education more aggressively as population oral health becomes better understood and are introduced into formal dentistry. The methods, strategies and plans to improve oral health through multiple levels and a more defined systems approach will become standard. Still, the current state of dental education indicates that the theory is addressed in a more dilute manner as noted in the mission and vision of dental schools which incorporate social determinants and patient-centered care into curriculum but do not indicate social ecology or bioecological theory as a framework for the curriculum. In addition, social ecology has yet to be used as a foundational theory in a cohesive national oral health strategy. There are chronic diseases which are very costly and other diseases which demand more attention because of their harmful nature. Dental disease is largely a silent epidemic (Benjamin, 2010). As science continues to emerge about the role of systemic infections originating in the mouth as a contributor to other negative health issues or as a confounding

SOCIAL ECOLOGY THEORY: ORAL HEALTH

factor for costly and potentially very damaging issues like preterm birth, and diabetes there will likely be a more cohesive national plan to address unmet dental disease on a population level (Benjamin, 2010). With this development, social ecology/CCPT theory will be well-suited as a foundational theory addressing the multiple systems of the individual. The theorys potential use in oral health can be found in the effectiveness of healthpromotion efforts which can be enhanced through multilevel intervention packages that combine both behavioral and environmental modification strategies (Winett, 1995). The social-ecological perspective emphasizes the advantages of multilevel interventions that combine complementary behavioral and environmental components. Examples of research approaches which combine population, clinical, and basic science relates to health disparities (Warnecke, 2008.) Strengths and Weaknesses of the Theory The strength of the model in relation to oral health is the depth of which it has been used in multiple public health issues especially in regards to chronic diseases. The theory has achieved a very high level of success in application to many disciplines. However, even though dental caries (cavities) is the most common childhood disease, there has been little national effort to address this via a social ecology theory (Benjamin, 2010.) There are several identified weaknesses of the theory which includes the fact that more research does not incorporate the more current adaptations of the model (Tudge, Mokrova, Hatfield & Karnik, 2009). The theory does not have much research in relation to its application to population oral health and the multiple systems for intervention much like tobacco use or obesity does. Considering dental disease is the most common health issue in the nation, it is a terrific opportunity for this theorys use to be enhanced (Benjamin, 2010). Conclusions

SOCIAL ECOLOGY THEORY: ORAL HEALTH

The social ecology/bioecological theory and its use in oral health promotion including multiple areas of analysis, and various methodologies available in research will be a strong foundation for future research in oral health. There will many opportunities to make inroads in learning about the systems related to population oral health and the Bronfenbrenner theory can support innovative research, practice enhancements, policy changes and hopefully improvement in population oral health.

SOCIAL ECOLOGY THEORY: ORAL HEALTH

References Benjamin, R. M. (2010). Oral Health the Silent Epidemic. Public Health Reports. 125(2). 158159. Bensley, R. J., Brookins-Fisher, J. (2009). Community Health Education Methods: A Practical Guide. Sudbury, MA: Jones and Bartlett. Bronfenbrenner, U. (1979) The Ecology of Human Development. Cambridge, MA: Harvard University Press. Bronfenbrenner, U. (1994). Ecological models of human development. International Encyclopedia of Education. 3, 1643-1647. Bronfenbrenner, U., Morris, P. A. (1998). The ecology of developmental processes. Handbook of Child Psycology(5th Ed. Vol. 1) New York: Wiley. Bronfenbrenner, U., Morris, P. A. (2006). The Bioecological Model of Human Development. Handbook of Child Psychology. New York: Wiley. Bronfenbrenner, U., Ceci, S. J. (1994). Nature-nuture reconceptualized in developmental perspective: A bioecological model. Psychological review. 101 (4) 568. Bronfenbrenner, U. (Eds.). (2005); Making Human Beings Human: Bioecological Perspectives on Human Development. Thousand Oaks, CA: Sage Publications. Bronfenbrenner & Evans, G. W. (2000). Developmental Science in the 21st Century: Emerging Questions, Theoretical Models, Research Designs and Empirical Findings. Social Development. 9(1), 115125. Doll, R. & Hill, A. B. (1954). The Mortality of Doctors in Relation to their Smoking Habits. British Medical Journal. 1(4877): 14511455.

SOCIAL ECOLOGY THEORY: ORAL HEALTH

Glanz, K.; Rimer, BK.; Viswanath, K. (2008) Health Behavior and Health Education, 4th ed. San Francisco: John Wiley & Sons, Inc. McLaren, L., Hawe, P. (2005). Ecological Perspectives in Health Research. Journal of Epidemiology and Community Health 59: 614. Quinn, L.A., Thompson, S.H., Ott, M.K. (2005). Application of the Social Ecological Model in Folic Acid Public Health Initiatives. Journal of Obstetric, Gynecologic, & Neonatal Nursing, Principles and Practice. 34:672-681. Simons-Morton, B., McLeroy, K.R., Wendel, M. L. (2012). Behavior Theory in Health Promotion Practice and Research. Burlington, MA: Jones and Bartlett Learning. Tudge, J., Mokrova, I., Hatfield, B. E., Karnik, R. B. (2009). Uses and Misuses of Bronfenbrenner's Bioecological Theory of Human Development. Journal of Family Theory & Review, 1(4), 198210. Warnecke, R. B., Oh, A., Breen, N., Gehlert, S., Paskett, E., Tucker, K. L., Lurie, N., Rebbeck, T., Goodwin, J., Flack, J., Srinivasan, S., Kerner, J., Heurtin-Roberts, S., Abeles, R., Tyson, F. L., Patmios, G., and Hiatt, R. A. (2008). Approaching Health Disparities from a Population Perspective: The National Institutes of Health Centers for Population Health and Health Disparities. American Journal of Public Health, 98(9), 1608-1615.doi: 10.2105/AJPH.2006.102525 Winett, R. A. (1995). A framework for health promotion and disease prevention programs. American Psychologist, 50(5), 341-350. doi: 10.1037/0003-066X.50.5.341

10

SOCIAL ECOLOGY THEORY: ORAL HEALTH

11