Macrosystem Levels Research Articles

No struggle, no progress: Taking the anti-racism conversation to a deeper level.

In order to promote ongoing dialogues about how to address racism in health care, the 2021 Forum on Behavioral Science included a workshop on how to take antiracism activities and conversations to a deeper level than what is typically offered. The workshop followed up on a previous antiracism plenary presentation at the 2020 Forum and was intentionally created to keep the importance of antiracism efforts on the forefront of behavioral science and medical education. The currently described presentation provided some background on how health inequity evolved in the United States. It also included information on the role that racism has played in the development of inequities in health care, the profession of medicine and medical education. Presenters included several activities specifically chosen to promote honest, open conversations about power imbalances that promote discrimination on the micro and macrosystem level. Participants were encouraged to start working on specific goals and ideas on how to conduct these activities and challenging conversations in their home institutions.

Theorising Health System Resilience and the Role of Government Policy- Challenges and Future Directions Comment on "Government Actions and Their Relation to Resilience in Healthcare During the COVID-19 Pandemic in New South Wales, Australia and Ontario, Canada".

Resilient healthcare (RHC) emphasises the importance of adaptive capacity to respond to unanticipated crises such as the global coronavirus disease 2019 (COVID-19) pandemic but there are few examples of RHC research focusing on the decisions taken by macro level policy makers. The Smaggus et al paper analyses the actions of two governments in Canada and Australia as described in media releases from a resilience perspective. The paper clearly articulates the need for conceptual clarity when analysing system resilience, and integrates three theoretical perspectives to understand the types of government responses and how they were related to resilience. The paper makes a valuable contribution to the developing RHC evidence base, but challenges remain in identifying conceptual frameworks, researching macro level resilience, including identifying and accessing reliable macro level data sources, analysing interactions between macro, meso and micro system levels, and understanding how resilience manifests at different temporal and spatial scales.

Examination of Ecological Systems Contexts Within a Latino-Based Community Sport Youth Development Initiative.

Youth Development Programs (YDPs) can serve as effective mechanisms to alleviate social and psychological adversities while enhancing and developing resilience among youth. Recently, more YDPs have incorporated sport within Sport for Development (SFD) models to achieve these goals. Due to the growing Latino population in the US and the wide achievement gap between Latinos and other demographic populations, there is a need to explore programs that may support individual development as well as long-term change with regard to social inequality. There is also a need to better understand the ecological contexts within SFD programs and how these contexts may support underserved youth. Specifically, using an ecological systems perspective, this study seeks to explore the implementation of a sport program by a YDP in order to examine the ecological processes that may support or inhibit the efficacy of sport programs working with underserved youth. Juntos is a YDP that primarily serves Latinx youth and families by assisting youth with graduating high school and pursuing higher education opportunities. Juntos incorporates two annual soccer tournaments (i.e., Kicking it with Juntos and Copa Unidos). A qualitative case study approach was implemented in two counties in North Carolina. Interviews were conducted with tournament participants, county coordinators and planning committee members. Findings found three key themes related to three ecological levels 1. At the Microsystem level, sport was implemented to engage youth and connect to non-sport program outcomes, but divergent perceptions of goals among stakeholders potentially inhibited intentional implementation. At the Mesosystem level, sport provided a mechanism to engage in collaborative relationships and encouraged parental participation. At the Macrosystem level, sport celebrated Latino culture and attempted to address social barriers facing Latinx youth, but some aspects of culture may have created barriers to access for girls. Findings suggested that while the programs emphasized mesosystem engagement, more integration across exosystem and macrosystem levels may be needed for sustainable outcomes.

Trajectories of subjective health status among married postmenopausal women based on the ecological system theory: a longitudinal analysis using a latent growth model

This study investigated the trajectory of subjective health status in married postmenopausal women and aimed to identify predictive factors affecting subjective health status. Data were obtained from women who participated in wave 4 (2012) of the Korean Longitudinal Survey of Women & Families Longitudinal Study and continued to the latest phase (wave 7, 2018). A latent growth model (LGM) was used to analyze data from 1,719 married postmenopausal women in the framework of the ecological system theory. The mean age of the participants at wave 4 was 56.39±4.71 years, and the average subjective health status was around the midpoint (3.19±0.84). LGM analysis confirmed that subjective health status decreased over time (initial B=3.21, slope B=-0.03). The factors affecting initial subjective health were age, body mass index, frequency of vigorous physical activity (microsystem level), marital satisfaction (mesosystem level), and medical service utilization (macrosystem level). Medical service utilization and the frequency of vigorous physical activity were identified as predictive factors affecting the slope in subjective health status. The model fit was satisfactory (TLI=.92, CFI=.95, and RMSEA=.04). This analysis of the trajectory of subjective health status of married postmenopausal women over time confirmed that subjective health is influenced by overall ecological system factors, including the microsystem, mesosystem, exosystem, macrosystem, and chronosystem. Therefore, it is necessary to assess physical activity and support policies promoting access to medical services in order to improve the subjective health status of married postmenopausal women.

Are Social Vulnerability and Family Social Support Associated with Children's Psychiatric Symptoms?

Social influence can shape early childhood at different levels. We explored the association between social vulnerability and lifetime caregiver alcohol use with children's psychiatric symptoms. Multivariable logistic regression assessed the association between child psychiatric symptoms and social vulnerability among 1275 preschool child-caregiver pairs with lifetime caregiver alcohol used as a control variable. Of the children, 15.78% (95% CI 15.17-16.42) had internalizing symptoms, 2.49% (95% CI 2.19-2.83) had externalizing symptoms, and 9.36% (95% CI 8.88-9.86) had internalizing/externalizing symptoms. High social vulnerability was positively correlated with internalizing (aRRR 1.54; 95% CI 1.41-1.68) and internalizing/externalizing symptoms (aRRR 1.77; 95% CI 1.58-2.00). Low family support was strongly associated with internalizing/externalizing symptoms (aRRR 2.60; 95% CI 2.20-3.10). Lifetime caregiver alcohol use was positively correlated with all three psychiatric symptoms (aRRR 1.33; 95% CI 1.18-1.51; aRRR 1.13; 95% CI 1.06-1.59; and aRRR 1.26; 95% CI 1.12-1.42). Their association with children's mental health outcomes calls for social policy changes at the macrosystem level.

What is needed for continuity of care and how can we achieve it? – Perceptions among multiprofessionals on the chronic care trajectory

BackgroundContinuity of care (CoC) implies delivery of services in a coherent, logical and timely fashion. Continuity is conceptualized as multidimensional, encompassing three specific domains – relational, management and informational continuity – with emphasis placed on their interrelations, i.e., how they affect and are affected by each other. This study sought to investigate professionals’ perceptions of the prerequisites of CoC within and between organizations and how CoC can be realized for people with complex care needs.MethodsThis study had a qualitative design using individual, paired and focus group interviews with a purposeful sample of professionals involved in the chain of care for patients with chronic conditions across healthcare and social care services from three different geographical areas in Sweden, covering both urban and rural areas. Transcripts from interviews with 34 informants were analysed using conventional content analysis.ResultsCoC was found to be dependent on professional and cross-disciplinary cooperation at the micro, meso and macro system levels. Continuity is dependent on long-term and person-centred relationships (micro level), dynamic stability in organizational structures (meso level) and joint responsibility for cohesive care and enabling of uniform solutions for knowledge and information exchange (macro level).ConclusionsAchieving CoC that creates coherent and long-term person-centred care requires knowledge- and information-sharing that transcends disciplinary and organizational boundaries. Collaborative accountability is needed both horizontally and vertically across micro, meso and macro system levels, rather than a focus on personal responsibility and relationships at the micro level.

The challenges of conducting mental health research among resettled refugee populations: An ecological framework from a researchers’ perspective

Researchers who are aiming to conduct high quality mental health research in resettled refugee populations are likely to experience multiple challenges in their work. To our knowledge, there is no overview of these challenges and their implications for the quality of research from a researchers’ perspective. We conducted a systematic literature search to further complete the overview of challenges. Lastly, we placed the findings of the thematic analysis and the literature search in a conceptual framework derived from the social ecological model of Bronfenbrenner. Our findings indicate that common research challenges, such as high drop-out rate or low treatment fidelity, must be understood in the light of multiple levels such as the individual, microsystem, mesosystem, exosystem and macrosystem level. This will help future researchers to increase the understanding of the complex interplay of factors that play a role when facing challenges in their work and to create possibilities for improvement.

Health insurance expansion and family violence prevention: A conceptual framework

Family violence, including child maltreatment (CM) and intimate partner violence (IPV), plagues far too many American families, particularly those in low-income communities. CM and IPV are intertwined and impose a significant emotional, health and financial burden on children and families and an economic burden on our country. Although these and other forms of violence are influenced by shared risk factors across the socioecological spectrum, prevention efforts typically intervene on a single type of violence at a microsystem level via individual or family intervention. Research is needed to identify policies operating at macrosystem levels that reduce, at scale, multiple forms of violence affecting children. In this paper, we propose a three-step theory of change through which health insurance expansions might reduce rates of CM and IPV, using Medicaid expansion as an exemplar. The proposed framework can inform research examining the link between health insurance and the primary prevention of CM and IPV.

Local ecological knowledge and resilience of ethnomedical systems in a changing world – South American perspectives

We are experiencing an era of great and rapid changes that directly affect biocultural systems. Ethnomedical systems are complex social-ecological structures and processes affected by drivers that may lead to changes in the trajectories of these systems, or even to collapse, according to their resilience and adaptation capacity. We examine ethnomedical systems in the context of social-ecological resilience, discussing how these systems are adapting and responding to current challenges, threats and risks. Seven case studies from Indigenous Peoples and Local Communities living close to forest ecosystems in South America (Argentina, Brazil, and Paraguay) provide an overview and offer strategies for research and public policies related to biocultural diversity and health. We discuss some nuances of ethnomedical systems resilience, such as the importance of utilitarian redundancy, the effects of biomedicine and technologies on traditional practices, including the hybridization process; the effects of contaminated environments in the use of plants; the influence of COVID-19 on traditional practices and peoples’ creative responses to the pandemic; and the influence of Brazilian health care policies for Indigenous Peoples. Based on these case studies at different spatial scales (individual, local community, metacommunity, and macrosystem levels), we discuss the adaptation, transformation, and resilience of ethnomedical systems, as well as the role of local ecological knowledge in this process. We highlight new perspectives for research, actions and public policies that can favor the quality of life and health of Indigenous Peoples and Local Communities.

The Value of and Need for Health Services and Policy Research that Focuses on Macro System-Level Challenges.

Much of health services and policy research is applied. We offer four provocations to stimulate thinking about the relationship between research and the "systems" it aims to influence. We conclude that a focus on partnership implies that researchers need to be empathetic to the timelines and needs of policy makers, while true relationships are bidirectional. Focusing on the priorities of "systems" will emphasize short-term issues. This leads to researchers often conducting post-implementation evaluation, where they have had little involvement in policy or intervention design. Finally, a focus on single-project return of investment will tend to undervalue riskier - but also potentially more rewarding - research.

RETRACTED ARTICLE: A thematic analysis of system wide learning from first wave Covid-19 in the East of England

BackgroundThe Covid-19 pandemic has created an unprecedented challenge for health and social care systems globally. There is an urgent need for research on experiences of COVID-19 at different levels of health systems, including lessons from professional, organisational and local system responses, that can be used to inform managerial and policy responses.MethodsThis paper presents the findings from a thematic analysis of front-line staff experiences working across the Norfolk and Waveney integrated care system (ICS) in the East of England during April and October 2020 to address the question “What are the experiences and perceptions of partner organisations and practitioners at multiple levels of the health system in responding to COVID-19 during the first wave of the pandemic?” This question was posed to learn from how practitioners, interdependent partner organisations and the system experienced the pandemic and responded. 176 interview transcripts derived from one to one and focus group interviews, meeting notes and feedback from a “We Care Together” Instagram campaign were submitted for qualitative thematic analysis to an external research team at a regional University commissioned to undertake an independent evaluation. Three phases of qualitative analysis were systematically undertaken to derive the findings.FindingsThirty-one themes were distilled highlighting lessons learned from things that went well compared with those that did not; challenges compared with the celebrations and outcomes; learning and insights gained; impact on role; and system headlines. The analysis supported the ICS to inform and capitalise on system wide learning for integration, improvement and innovations in patient and care home resident safety, and staff wellbeing to deal with successive waves of the pandemic as well as prioritising workforce development priorities as part of its People Plan.ConclusionsThe findings contribute to a growing body of knowledge about what impact the pandemic has had on health and social care systems and front-line practitioners globally. It is important to understand the impact at all three levels of the system (micro, meso and macro) as it is the meso and macro system levels that ultimately impact front line staff experiences and the ability to deliver person centered safe and effective care in any context. The paper presents implications for future workforce and health services policy, practice innovation and research.

Shaping science, technology, engineering and mathematics curriculum in Australian schools: An ecological systems analysis

Improving young people’s engagement in science, technology, engineering and mathematics (STEM) is being promoted worldwide as a means of addressing projected shortfalls in expertise needed to further nations’ economic, social and environmental goals. Responding to this, schools are reforming traditional discipline-based curricula into interdisciplinary approaches based on problem and project-based designs, to make STEM learning more relevant and meaningful for students. This study drew on a dataset of 449 Australian principal and teacher interviews, to identify factors influencing STEM curriculum in their schools. It utilised Ecological Systems Theory to build understanding relating to the influence of activities and outputs originating at macro, exo and meso system levels, on STEM curriculum and practices in classrooms. Results demonstrated how many innovative schools were able to successfully leverage community, business and national resources to enhance their STEM curriculum, while others struggled due to limitations imposed by geographic or socio-economic factors, or limited access to resources, expertise or advice. Central to achieving this was the powerful influence of principals’ and teachers’ proximal processes and developmental assets in establishing effective and engaging interdisciplinary STEM curricula, despite constraints imposed by, at best, ambiguous national and state curriculum and policies, rigid assessment regimes and compliance-focused reporting requirements.

Examining the Macrosystem Level of Influence on Community Health Worker Effectiveness in the State of Nebraska: A Qualitative Approach.

Community health workers (CHWs) serve as the linkage between community and providers and are stakeholders for bridging services to the public. However, integration of CHWs into health care organizations is often lacking. This study explored macrosystem level barriers faced by CHWs and their ability to do their jobs effectively. Using qualitative interviews from CHWs (n = 28) in Nebraska, we used an abductive approach to derive the following themes: (1) CHWs and client macrosystem barriers, (2) CHW workforce supports, and (3) macrosystem solutions for CHW workforce sustainability. Study results also found various macrosystem barriers affecting CHW workforces including immigration policies, insurance policies, funding sources, supervisor support, and obstacles for health seeking of clients. Moreover, through the lens of CHWs, results revealed the need to provide and advocate for solutions that prioritize the needs of CHWs as they continue to fill a crucial gap in community healthcare systems.

Use of Soft Systems Methodology for Implementing Clinical Practice Guidelines in a General Hospital

Background: It is challenging to implement evidence-based care and update and improve health care policy. Adhering to evidence-based Clinical Practice Guidelines (CPGs) serves as a guide for making decisions based on the best evidence and making an attempt to improve the quality of patient care and outcomes. Despite the need for implementing CPGs in Iranian hospitals, the concept and implementation method of CPGs are not clear yet. This action research aims to propose the soft systems methodology (SSM) to facilitate the implementation of CPGs in a general hospital in Iran. Methods: We employed the SSM to conceptualize the situation for the implementation of CPGs. Semi-structured in-depth interviews and group discussions with different stakeholders were used to define the purposeful activity model. The SSM tools and techniques were used to identify the main areas of change and select necessary measures to facilitate the implementation of CPGs. Flexible qualitative methods for data collection and analysis were utilized throughout the study. Results: Applying SSM for implementing CPGs could generate knowledge by recognizing hyper-complexity in healthcare setting, adopting an attitude of inquiry, and fostering dynamic changes in diverse and numerous worldviews of professionals in the accommodation process. This knowledge can provide a model for the successful implementation of CPGs at a macro-system level and facilitate the persuasion process for its implementation at the mesosystem level. More importantly, adopting SSM can create iterative learning loops over time and, thus, help the clinical microsystems face future healthcare complexities. Conclusion: The application of systems thinking approaches, especially SSM is recommended for implementing CPGs and addressing complex issues in healthcare settings and other system levels.

Reinvigorating an Academy of Medical Educators Using Ecological Systems Theory.

The educational framework of communities of practice postulates that early learners join medical communities as social networks that provide a common identity, role modeling and mentorship, and experiential learning. While being elected into a medical society is an honor, member engagement in these groups can falter if the society membership is seen as an honorific rather than one requiring continuing participation. As an example, Academies of Medical Educators have been established by many academic medical centers to encourage collaboration, skill development, professional identity formation, and scholarship. The University of North Carolina established the Academy of Educators in 2006 to create a diverse community of educators to promote the scholarship, teaching skills, and professional identity of educators. Despite rapid growth to over 500 members, we had less than 30 participants at events over the 2017-2018 academic year. To increase member engagement and participation, our academy leadership team used Bronfenbrenner’s Ecological Systems Theory to design interventions at each layer of environmental influence, specifically at the microsystem, mesosystem, exosystem, macrosystem, and chronosystem levels. In this paper, we describe the multipronged approach used to increase the University of North Carolina Academy of Medical Educators event attendance from 30 to 1,000 faculty participants over the course of one academic year (2018-2019). This paper provides a model as to how medical societies can use ecological systems theory as a natural and comprehensive approach to plan and improve their member engagement and experience.

Оцінка стану економічної безпеки в контексті людиноорієнтованого підходу.

The article is concerned with assessing the state of economic security using the human-oriented approach. It is substantiated that at the macrosystem level, the economic security of the country will characterize such a state that, in case of exposure to external and manifestation of internal threats, depending on the degree of sensitivity, can ensure the preservation of its stability at a sufficient level from the point of living standards, preservation and development of human capital. To form a set of indices, indicators of the Inclusive Economic Growth and Development Index, computed by the World Economic Forum, are used. To select the relevant indices of official methodological recommendations for assessing economic security in Ukraine, they were examined on the basis of determining the degree of correlation with the values of inclusive development in the countries of the world. A content-based comparison of groups and the composition of indicators for assessing economic security in accordance with the methodological recommendations with the specified index indicated the presence of a significant divergence between them. Low impact on inclusive development in indicators of added value of industry to GDP, energy imports, livestock production and food production index, a discriminatory role of agriculture in inclusive development of the country are identified. The assessment model of economic security includes indicators of macroeconomic security, investment-innovation, financial, security for business, foreign economic, energy, security in the field of education and demography. Based on a sample of countries comparable in terms of incomes with Ukraine, the value of the complex of indicators of economic security of Ukraine for 2014–2020 is normed. The assessment of the integral index points out the average level of economic security relative to the level of incomes similar in countries. Macroeconomic and security for business activities are the worst. It is noted that the full use of indicators of inclusion in economic security is complicated by the lack of statistics for most countries, in particular, indicators of the welfare of the population from the point of view of accumulated assets. The conclusion is made about the need to develop household statistics for the adequate application of the human-oriented approach in assessing the economic security.

Reference framework of the management concept of the evaluation of school results

The article approaches the management of the evaluation of school results through the prism of the frame of reference of the concept. Several researchers and theorists define relief in its accentuated intensity and extension. The concept of general management defines, on the one hand, the process of leading an organizational entity at macrosystem level, for example state, nation, state confederations or microsystem, such as: institutions, enterprises, organizations, and on the other hand , indicates the emerging springs of practice, science and art alike. The term management, ultimately, refers to the science of leading organizations and their scientific leadership.

Reflections on the ‘Just Price’ in Times of Crisis (with Reference to Coronavirus … but not only)

Abstract The debate about the ‘just price’ has ancient origin and returns forcefully to the scene when, in the event of crises of various kinds, there is a rapid and significant increase in prices of given goods or services. The main issue is whether price increases of such a nature could, or should, be considered illicit and ground the issue of sanctions against the firms increasing prices, thus focusing on a macro-systemic level of analysis. The central part of the article reviews different theories on what a ‘just price’ should be and focuses on the idea that a price is ‘just’ when it functions as an index of relative scarcity in free markets. It is claimed that such a function deserves protection by Italian and EU law. Therefore price adjustments in response to shocks cannot and should not be considered illegal: it is unacceptable to sanction private firms by attributing them the wrong of not having substituted themselves, at their own expense, for the exercise of a public function (that of making sure that price increases do not put at risk solidarity and other constitutional principles).

Women’s sexual satisfaction in the context of midlife relationships: examining an ecological model

ABSTRACT This study examined an ecological model of sexual satisfaction in midlife women. Participants were 1,411 midlife women who participated in the Midlife in the United States (MIDUS) study. Regression analyses were used to test the hypothesis that an ecological model – including the macrosystem level variable of religiosity, the exosystem level variables of SES, social support, and parenthood, the mesosystem level variables of affectual solidarity, relationship length, and sexual functioning, and the microsystem level variables of age, negative affect, and physical health – would together predict sexual satisfaction. Partial support for an ecological understanding of sexual satisfaction was found.

A-13 Stepping into Action: The Role of Neuropsychologists in Social Justice Advocacy

Abstract Objective The current pandemic shed a necessary light on chronic systemic inequities. Despite awareness of the importance of diversity, equity, social justice, and advocacy, actionable change has been slow. The field of neuropsychology and psychology were founded on principles of universal rights for all humans, yet it has largely neglected social justice activities. Social justice and advocacy efforts are not universally embedded in education/training curriculums, nor in licensure requirements. If the field is pledging to move towards equity, systemic change is required. We offer practical considerations on how advocacy can lead neuropsychologists toward equity and social justice. Data Selection A review of the literature on racism, social justice, and health/mental health disparities, was conducted in the fields of neuropsychology, clinical psychology, counseling psychology, medicine, and public health, to form a systems-based approach to advocacy with actionable steps that can be taken by all. Tenents of critical consciousness, transformative learning, transformative justice and socially responsible neuropsychology emerged. Data Synthesis We utilize an ecological systems framework (microsystem, mesosystem, exosystem, and macrosystem levels) to provide a graded, developmental approach for transitioning to a social change agent. Recommendations are offered to provide guidance on addressing inequities at multiple levels in an effort to uphold human rights and protection of all. Conclusion Neuropsychology has the opportunity to blaze a new trail that can effectively protect, include, and nurture all of its constituents equitably rather than equally. Transforming our field is possible through stepping into action by equipping our trainees and professionals with the tools to become agents of social change.