What is evidence-based systems thinking in public health?

Learning Objectives

  • What is evidence-based systems thinking in public health?
    • Define Systems Thinking
    • Describe Social Ecological Models (SEM)
    • Define social, environmental, nutritional, and healthcare determinants of health
    • Explain the value of using systems thinking tools in investigating public health issues

Systems Thinking in Public Health

  • Comprehensive approach that views health outcomes as the result of complex, interconnected systems rather than isolated factors.
  • Recognizes that individual and population health emerges from dynamic interactions between biological, social, environmental, economic, and policy factors.

Benefits of Systems Thinking in Public Health

  • Understanding Interconnections
    • View health issues within the broader context of social, economic, environmental, and political factors
    • Identify underlying drivers of health problems (root cause analysis) rather than just treating symptoms
    • Reveal how different factors influence each other across multiple levels (individual, community, policy)
  • Improved Problem-Solving
    • Help anticipate how interventions might create ripple effects throughout the system and avoid unintended consequences
    • Identify where small changes can produce significant system-wide improvements
    • Develop interventions that address structural issues for longer-lasting impact
    • Encourage collaboration between healthcare, education, housing, transportation, and other sectors
  • Addressing Health Equity
    • Examine how systems perpetuate or can eliminate health disparities
    • Multi-level interventions: Target individual, community, and policy levels simultaneously
    • Consider how resources and decision-making authority are distributed

Social Ecological Models

  • Theoretical frameworks that recognize health behaviors and outcomes result from the dynamic interaction between individuals and multiple levels of environmental influence.
  • Move beyond individual-focused approaches to consider the complex web of factors that shape health at personal, interpersonal, community, and societal levels.

Examples of Social Ecological Models

  • Source references:
    • Public Health: An Introduction to the Science and Practice of Population Health (Shultz, Sullivan, Galea, 2024)
    • https://sites.uw.edu/somalttest1/2017/08/12/social-ecological-model/

Domains of Influence (Over the Life Course) and Health Outcomes

  • Domains of Influence (Over the Life Course): Biological, Behavioral, Physical/Built Environment, Sociocultural Environment, Health Care System, Health Outcomes
  • Level: Individual
    • Taste Predispositions, Nutritional Status, Nutrition Metabolism, Nutrigenomics, Metabolomics, Microbiome, Food Allergies and Intolerances
    • Dietary Intake, Dietary Habits, Eating Patterns, Coping Strategies
    • Personal Food Environment and Access (exposure to fast food at home)
    • Food Preferences, Sociodemographic factors (discretionary income)
    • Food Literacy and Preparation Skills
    • Limited English
    • Cultural Identity/Acculturation
    • Response to Discrimination
    • Insurance Coverage, Access, Utilization
    • Health Literacy
    • Treatment Preferences
    • Medical Nutrition Therapy
    • (Source: Agurs-Collins et al. 2024)
  • Level: Interpersonal
    • Maternal-Child Interaction, Feeding Practices (e.g., breastfeeding), Family Microbiome
    • Family Dietary Practices (e.g., family meals)
    • School/Work Dietary Behavior
    • Household Food Environment
    • School/Work Food Environment
    • Social Networks
    • Family/Peer Norms
    • Interpersonal Discrimination (e.g., dietary practice, body image)
    • Patient-Clinician Relationship
    • Medical Decision-Making (referral to Registered Dietitian)
    • Family/Organizational Health
  • Level: Macro (Fundamental) – Natural Environment
    • Topography, climate, water supply
    • Macrosocial Factors: Historical conditions, Political order, Economic order
    • Legal codes, Human rights doctrines
    • Social and cultural institutions, Ideologies (racism, social justice, democracy)
    • Inequalities: Distribution of material wealth, Employment opportunities, Educational opportunities, Political influence
  • Level: Intermediate (Meso/Community Level)
    • Built Environment: Land use (industrial, residential, mixed use), Transportation systems, Services (shopping, banking, health care facilities, waste transfer stations)
    • Public resources (parks, museums, libraries)
    • Zoning regulations
    • Buildings (housing, schools, workplaces)
    • Social Context: Community investment (economic development, maintenance police services), Policies (public, fiscal, workplace), Enforcement of ordinances (public, workplace), Community capacity, Civic participation & political influence, Quality of education
  • Level: Proximate (Micro/Interpersonal Level)
    • Stressors: Environmental, neighborhood, workplace and housing conditions; Violent crime & safety; Police response; Financial insecurity; Environmental toxins (lead, particulates); Unfair treatment
    • Health Behaviors: Dietary practices, Physical activity, Health Screening
    • Social Integration and Social Support: Social participation and integration; Shape of social networks and resources available; Social support
    • Social context: Discrimination; Patient-clinician relationships
  • Level: Health & Well-being (Individual or Population Levels)
    • Health Outcomes: Infant & child health (low birth weight, lead poisoning), Obesity, Cardiovascular diseases, Cancers, Injuries & violence, Infectious diseases, Respiratory health, Mental health, All-cause mortality
    • Well-Being: Hope, Despair, Life satisfaction, Psychosocial distress, Happiness, Disability, Body size and body image
    • Source: Schulz & Northridge, 2004

Social Ecological Model for PubHealth 500

  • Individual; Family; Relationships; Community; Institutions; Society; Culture
  • Historical Racial Context
  • Planetary Health; Climate
  • Planetary Health is the health of human civilization and the state of the natural systems on which it depends.
  • Historical Racial Context is the examination of how structural, systemic, and institutional racism has had profound impacts on health and health inequities.

Social Determinants of Health

  • Non-medical factors that influence health outcomes.
  • SDoH are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.

Healthy People 2030: Social Determinants of Health

  • SDoH can be grouped into 5 domains.
  • They impact people’s health, well-being, and quality of life.
  • They are major contributors to health disparities and inequities.

Determinants of Health

  • Nutritional Factors & Determinants of Health
  • Environmental Factors & Determinants of Health
  • Healthcare Factors & Determinants of Health
  • Social Determinants of Health

How do these frameworks fit together?

  • The Social Ecological Model provides the structure: levels where health influences occur from individual factors to policy and historical context.
  • Determinants of Health fill in the content: specific factors at each level that shape health outcomes.
  • Systems Thinking reveals the connections: how factors at different levels influence each other, create feedback loops, and sometimes produce unexpected results.

Group Activity

  • Activity 1: Identify examples of NUTRITIONAL determinants of health at each level of our SEM.
  • Activity 2: Identify examples of ENVIRONMENTAL determinants of health at each level of our SEM.

County Health Rankings (Model of Health)

  • County Health Rankings as a Public Health Data Source for Determinants of Health.
  • Interactive maps and data; Used by public health professionals, policymakers, and researchers.
  • Created by the University of Wisconsin Population Health Institute, Robert Wood Johnson Foundation.

County Health Rankings: Model of Health

  • Model of Health (County Health Rankings & Roadmaps, 2025) by University of Wisconsin Population Health Institute.
  • Emphasizes Social, Environmental, and Healthcare Determinants of Health.

Homework for Week 3

  • Finding Scientific Evidence for Risk/Protective Factors
  • Task: Find two PubMed articles that are meta-analyses or systematic reviews examining your health condition and a relevant factor (Social, Environmental, Nutritional, or Healthcare Determinant of Health) influencing that health condition.
  • Include:
    • Citation
      n - Study design
    • Geography
    • Exposures/factors measured
    • Study Objective (What questions does this review seek to answer?)
    • Summary of Findings
    • Confounding Variables
    • Limitations

Next steps

  • Schedule of HDR homework and Lab activities:
    • Submit HDR homework from Monday AM: Epidemiological Methods: Find & Analyze an Epidemiological Study
    • Monday PM: HDR homework: Epidemiological Methods: Description of Data Source
    • Wednesday AM: Distributions of sample data
    • Wednesday PM: Data Analysis: HDR Lab 1
    • Week 3: Submit Week 3 Reflection