A multi-level view on mental health in the workplace. (MHST601 assignment #2)
This unit’s topic of multi-level understandings of health is putting the puzzle pieces together on a more formalized way of viewing what health is and the many social determinants which influence health outcomes. In this blog I am exploring what an ecological model of health is, the variations of this model when applied to employee mental health, what the interventions at each level might look when applied to the workplace and finally, I’ll briefly touch on what level might be the “best” level to intervene at.
What is an ecological model of health?
“Ecological models of health behavior emphasize the environmental and policy contexts of behavior, while incorporating social and psychological influences.” (Sallis, et al., n.d.)
Sallis et al., writes that ecological models are both helpful in understanding the multi-faceted and complexity of health behaviors, as well as are valuable to practitioners and researchers to use as a framework to develop effective interventions for each level which influences health (n.d.). As I wrote in previous blogs, there is complexity behind the question What is health? and the various Determinants of health that impact the health of an individual and populations. However, by looking at a specific health concept or population through a social ecological model it can narrow the focus of the health intervention to specific levels within the system, no matter how large or small. An ecological model of health could be applied to the concept of mental health promotion in general, but I’m focusing my attention on how a social ecological model can apply to health promotion interventions targeted to employee mental health.
Variations of an ecological model of health
As I reflect on my experience in workplace health promotion and the many Social Determinants of mental health, an ecological model of health appears to be highly applicable to understanding how the workplace may influence the mental health and well-being of its employees. During my exploration of resources I found that there are variations of the CDC’s Social Ecological Model in the application to workplace health. The Social Ecological Model of Health from the Centers for Disease Control and Prevention (2022) distinguishes four levels within; Individual - Relationship – Community – Societal. Though, what I’ve found as I scanned the literature is that a number of studies on workplace mental health through a multi-level perspective often have study designs that use variations of this ecological model. In other words, they don’t all use the exact four levels from the CDC Social Ecological Model. As practitioners looking to translate research into practice it would certainly be simpler if all academic papers used the same terminology but that doesn’t seem to be the case.
For example, here are the levels of influence used within three different studies on ecological models of health and the workplace:
Intrapersonal – Interpersonal – Institution – Community - Policy (Golden & Earp, 2012)
Job Demands-Resources (JDR) model and the Individual-Group-Leader-Organization (IGLO) framework (Giusino, 2022)
Micro (individual) level, Meso (group) level, and Macro (organizational) level (Martin et al., 2016)
Though different terms are used to describe each level and each study has a different number of levels, the common thread amongst them all is that they range from the individual, up to the greater organizational influences.
Figure 1. This commonly referenced Social Ecological Model from the Centres for Disease Control and Prevention has four levels of influence, as shown above (2022).
Employee mental health interventions at each level
A three-level model
In the next step of my exploration I looked to see how, with its variations on levels, an ecological model of health can be applied to workplace health promotion interventions specific to employee mental health. The first is a study by Martin et al. which used a three-level ecological model of health; individual (micro), workgroup (meso) and organizational (macro), to analyze the impact that the workplace has on the mental health of employees (2016). Examples of interventions at each level are highlighted in the table below:
Individual (micro) | Workgroup (meso) | Organizational (macro) |
|---|---|---|
Training and resources on topics such as personal resilience and stress management strategies. | Work unit climate, which could include interpersonal relationships within a specific work branch or group. | Policies or procedures that protect worker mental health, such as a respectful workplace policy that has zero tolerance for workplace bullying. |
Table 1. Martin et al., (2016) use a three-level model to categorize interventions targeted at workplace mental health. This table summarizes examples of interventions which might be included at each of the three levels.
A dual model (two factors and four levels)
I imagine that much research will come out on the impact that the work environment had (and continues to have) on employee mental health during the COVID-19 pandemic, particularly for employees working in frontline health care. Taking a multi-level perspective on the impact that the workplace has on employee mental health allows for a more comprehensive view of the issue and could contribute to more effective interventions to support the psychological health of impacted workers. A study by Giusino, et al., (2022) stood out to me for its multi-level approach. The authors took a modified social ecological perspective to evaluate what supported and what was a barrier to health care worker mental health during the first wave of the pandemic in Italy. They used an integrated ecological framework of two models combined; Job Demand-Resources (JDR) and Individual-Group-Leader-Organization (IGLO) to retrospectively understand what the barriers/risks to worker mental health were, as well as what the protective factors/supports were to workers during this period of intense work demands. This was done through interviews with management and frontline staff and categorizing the job demand and job resources into the following four levels: individual, group, leader and organizational. A summary of their results is below.
Table 2. This table is from the qualitative study by Giusino et al. (2022) which summarizes the various demands (barriers/risks) and resources (supports or protective factors) for employee mental health for each of the four levels within the organization.
From reviewing reflections and blog posts from my peers who work in frontline healthcare, I can see that many health professionals observed in their peers or experienced firsthand emotional strain due to their work environment and/or additional work demands as a result of the COVID-19 pandemic. The application of the dual model in the study by Guisino et al., is, in my perspective, an effective way to highlight the importance of having interventions which target multiple levels. Employers should note that to support and protect employee mental health during periods of high work demands, such as what the pandemic had, that they must consider both the demands and resources at all levels. Because, many demands may be coming from the leader or organizational level, not just those which intervene at the individual level; which is often the level which workplace health initiatives target.
Which level is the best level to intervene?
Golden & Earp (2012) state that for the most effective delivery of health promotion initiatives a program or resource should address more than one ecological level and, when possible, include those that are more upstream. With that in mind, Golden & Earp (2012) reviewed 157 papers that were published in the academic journal Health Education and Behavior over a 20-year period. They found that 20% of interventions targeted the community level, while 6% targeted the policy level and 95% intervened at the individual level. This mirrors what I observe in my work related to workplace health promotion; that most employers are looking for programs that address individual employee behaviors rather than the larger system levels. Individual interventions are often in the form of training or resources such as stress management tips or resiliency education. Much less often are the interventions targeting changes to the organization or leader behavior.
The big picture
An ecological model of health is valuable to health practitioners and researchers to better understand and deliver effective health promotion initiatives, including organizations wanting to support employee mental health. As I highlighted early in this blog post, there appears to be different versions of the CDC’s four level Social Ecological Model of Health (2022) with different titles and numbers of levels. Though, each appear to effectively capture the scope of describing levels within an organization, in the context of employee mental health. To summarize, what I am gleaning most from this assignment is that a multi-level approach is relevant and valuable to consider when planning, delivering and evaluating health promotion initiatives targeted at supporting employee mental health. Looking at many levels is a critical step to putting the pieces together on what health is and its’ many determinants.
With all this being said, I would be amiss to not acknowledge the privilege that comes with employment, and even the contextual considerations for the type of work someone has based on social determinants of health. “Employment is one of the most fundamental social determinants of health and life changes …” and whether someone has paid employment or not is associated with their mental health state (Brydsten, et al., 2018, p. 7). This blog has taken the perspective of those who have employment, while acknowledging that the opportunity and access to employment is another important context that an ecological model could be applied to. When looking at the broader determinants of mental health the workplace is just one influencing factor.
- Kylie
References
Centers for Disease Control and Prevention. (2022, January 18). The Social-Ecological Model: A Framework for Prevention. Violence Prevention. https://www.cdc.gov/violenceprevention/about/social-ecologicalmodel.html.
Brydsten, A., Hammarström, A., & San Sebastian, M. (2018). Health inequalities between employed and unemployed in northern Sweden: a decomposition analysis of social determinants for mental health. International Journal for Equity in Health, 17(1), 59. https://doi.org/10.1186/s12939-018-0773-5
Giusino, D., De Angelis, M., Mazzetti, G., Christensen, M., Innstrand, S. T., Faiulo, I. R., & Chiesa, R. (2022). “We All Held Our Own”: Job Demands and Resources at Individual, Leader, Group, and Organizational Levels During COVID-19 Outbreak in Health Care. A Multi-Source Qualitative Study. Workplace Health & Safety, 70(1), 6–16. https://doi.org/10.1177/21650799211038499
Golden, S. D., & Earp, J. A. L. (2012). Social Ecological Approaches to Individuals and Their Contexts: Twenty Years of Health Education & Behavior Health Promotion Interventions. Health Education & Behavior, 39(3), 364–372. https://doi.org/10.1177/1090198111418634
Martin, A., Karanika-Murray, M., Biron, C., & Sanderson, K. (2016). The Psychosocial Work Environment, Employee Mental Health and Organizational Interventions: Improving Research and Practice by Taking a Multilevel Approach: Employee Mental Health: A Multilevel Approach. Stress and Health, 32(3), 201–215. https://doi.org/10.1002/smi.2593
Sallis, J. F., Owen, N., Fisher, E. B. (n.d.). Chapter Twenty – Ecological Models of Health Behavior. Health Behavior and Health Education. https://www.med.upenn.edu/hbhe4/part5-ch20.shtml
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