Applying the Social Ecological Model to Patients Suffering From HIV and AIDS

Interpersonal, social and organizational factors have been shown to contribute to a person’s behaviours and attitudes toward human immunodeficiency virus (HIV) using the Social Ecological Model (SEM) (Baral, Logie, Grosso, Wirtz, & Beyrer, 2013). Therefore, a persons behaviour toward HIV testing can be influenced by friends, family and others around them. Using SEM, there are also connections to HIV from peer influence and perceptions of risk, lack of awareness of partner testing and sexual behaviour, location of testing, and timing of testing (Dyson, Mobley, Harris, & Randolph, 2018). Worldwide, HIV and acquired immunodeficiency syndrome (AIDS) are presenting with challenges from the perspective of testing and treatment, creating and sustaining prevention strategies, and ensuring all treatments and prevention strategies are culturally and gender sensitive (Lanier & DeMarco, 2015).

Social Ecological Model

“The social ecological model holds that individual decisions and behaviours result from reciprocal interactions within and between the individuals social and physical surroundings” (Dyson, et al, 2018, pp.54). Among other models, there is unfortunately a lack of specificity and multi-level analysis that successfully incorporates the necessary contributing factors to HIV prevention and risk behaviours (Baral, et al, 2013). Through using the SEM, one can successfully describe the environment in terms of individual and interpersonal relationships, organizational structures, and social and community factors. The social ecological model can also provide a unique interpretation of the connectivity between the individual, relational, communal and societal factors that influence a person’s decision to take an HIV test. There is a multifaceted approach between HIV and a persons co-morbidities that the affected person may have that is apparent through the use of the SEM (Batchelder, Gonazlez, Palma, Schoenbaum, & Lounsbuty, 2015). The following diagrams give a visual understanding of how the social ecological model relates to HIV and AIDS risk factors and treatment.

Figure 1: An indication of the SEM levels of influence (Winch, 2012).

Figure 2: The SEM applied to the risk level for HIV (Baral, et al, 2013).

Even though human behaviours are complex and uncertain, the model can effectively isolate the tendencies and patterns of expected behaviour based on historical evidence and evidence-based practice (Batchelder, et al, 2015).

Individual Factors

Contributing factors identified by the SEM at the individual level for HIV include biological and/or behavioural characteristics associated with the vulnerability to acquire or transmit the infection (Baral, et al, 2013). Educational needs have been identified through using SEM to show that by encouraging people to practice safe sex by using a condom during each sexual encounter and testing for HIV after each sexual encounter and every six months depending on the number of sexual partners will aid in the prevention of HIV and AIDS (Dyson, et al, 2018).

Interpersonal Factors

Interpersonal networks found by applying SEM include family, friends, neighbours and others that may directly influence the health behaviours of the individual (Baral, et al, 2013). Studies have shown that women are typically unaware of how many partners their partner has had or if their partner had been recently tested for HIV. Those who complete testing unfortunately assume that if they have tested negative, then their most recent partner must be negative as well (Dyson, et al, 2018). Overall, SEM has shown that individual experiences, environment, support systems and cultural beliefs are key predictors of depression, and HIV risk (Lanier & DeMarco, 2015). By applying SEM to interpersonal factors, it is evident that individuals with lower levels of education are: (a) less likely to use preventative measures against HIV; (b) less likely to use condoms; and (c) their education levels and HIV/AIDS related knowledge are highly correlated with higher rates of depression symptoms and major depression diagnoses are common (Lanier & DeMarco, 2015).

Organizational Factors

The laws and policies of the province or territory provide the general framework for determining the marginalized populations and the direction of funding from federal governments (Baggio, et al., 2016). Testing for HIV has occurred in the health department, physician’s office, on college and university campuses, during outreach programs, and at community-based clinics. Studies have shown that many people are still unaware, despite educational blitzes, that there are also oral and urine testing available as well as blood tests to test for HIV (Dyson, et al, 2018). The following diagram describes how SEM can be applied to the policies to decrease the risk factors for HIV and AIDS.

Figure 3: The social ecological model applied to Public Policy (Winch, 2012).

Social and Community Factors

The social ecological model has shown that community environments can either promote or hinder healthy lifestyles. Social and community factors include network ties, relationships between organizations and groups, and geographical regions (Baral, et al, 2013). Peer influences have been shown to be the most persuasive contribution to a person’s decision-making processes (Dyson, et al, 2018). Unfortunately, while there are robust discussions at the social level around current and potential partners amongst young people, the discussion rarely revolves around HIV testing, prevention, and risk. Young people are eager however, to discuss these issues during educational events with the presentors (Dyson, et al, 2018). When applying SEM to HIV prevention at the social and community level, interventions focused on condom use have show a considerable increase in the use of condoms (Baral, et al, 2013). Economic, relational, and cultural normative influences, including those related to gender role, abuse and oppression are associated with an increased incidence of HIV among African Americans (Lanier & DeMarco, 2015). In areas where SEM has not been utilized, shame and stigma have shown to create disruptions in all microsystems where women develop (Lanier & DeMarco, 2015). The following diagram outlines how SEM can be applied to the social and community influences of HIV and AIDS.

Figure 4: Applying SEM to social and community factors (Winch, 2012).

AIDS/HIV risk Factors

African Americans account for 44% of new AIDS cases in the united states each year, 23% of those are African American women aged 13-24 versus 16% of white women (Lanier & DeMarco, 2015). Only 34.5% of these young adults have been tested, and 60% are unfortunately unaware they carry the disease (Dyson, et al, 2018). The social ecological model brings to light that the lack of adequate testing could be due to medical mistrust, living environments, multiple partners and hidden forms of bias. (Dyson, et al, 2018). An assessment using the SEM shows the connections between HIV infections, substance use and violence and that the most significant risk factors involve a complex and robust relationship between the socio-environmental and the inter and intra personal factors such as emotional distress, substance use, violence, poverty, low self-worth, high risk sexual behaviours, and condom use (Batchelder, et al, 2015). The following diagram show how the risk factors for HIV and AIDS are interconnected through the lens of SEM.

Figure 5: A loop diagram showing the pathways between risk factor variables (Batchelder, et al, 2015).

AIDS/HIV Prevention

Prevention is the key to decreasing the spread of the infection. This can involve increasing HIV testing compliance. The Center for Disease Control (CDC) recommends testing of all person between 18 – 24 years of age (Dyson, et al, 2018). To successfully decrease the incidence of HIV, applying SEM to the approach includes a need to address a multi-level prevention strategy (Baral, et al, 2013). Health units doing educational blitzes on college and university campuses in an effort to reach as many young people as possible to educate about HIV testing, sharing injection devices, safe housing, case management and safe sex education (Baral, et al, 2013). Education also needs to be directed at helping young people understand how to initiate conversations about AIDS and HIV with prospective partners and ensuring protection is used (Dyson, et al, 2018). Through the use of SEM, we gain a detailed understanding of the risk factors of those living with and at a high risk for HIV/AIDS, and with this information we can reshape intervention strategies to better meet the needs of the target population (Batchelder, et al, 2015). With SEM, multi-level interventions have been show to be highly effective in providing a strong partnership between the required multidisciplinary team members (clinicians, public health and community practitioners, researchers and policy makers). Initially the interventions are directed at improving self-worth and focusing on decreasing substance use, therefore building resiliency and eventually working to increase economic freedom. With each step forward, the individual begins to feel a sense of empowerment which can be significantly more effective then solely addressing intrapersonal or socio-environmental factors (Batchelder, Gonazlez, Palma, Schoenbaum, & Lounsbuty, 2015; Lanier & DeMarco, 2015).

Conclusion

Negative tests can give people a false sense of security that they are have not contracted HIV (Dyson, et al, 2018). The social ecological model effectively guides the discussion among key populations who are at higher risk and gives a better understanding of HIV and its transmission (Baral, et al, 2013). The social ecological model shows that the risk factors for HIV, and those who are affected, is a dynamic and complex subject. The model has helped to conceptualize the approach to those at high risk for HIV infections by: (a) showing that there is rarely a single cause; (b) those at highest risk have multiple levels of influence; (c) there are variations due to even small changes in one or more factors over time; and (d) risk and prevention are derived from both socio-environmental and individual-level processes (Batchelder, et al, 2015).

References

Baggio, J. A., Burnsilver, S. B., Arenas, A., Magdanz, J. S., Kofinas, G. P., & Domenico, m. D. (2016). Multiplex social ecological network analysis reveals how social changes affect community robustness more than resource depletion. Proceedings of the National Academy of Sciences of the United States of America, 113(48), 13708-13713. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5137762/

Baral, S., Logie, C. H., Grosso, A., Wirtz, A. L., & Beyrer, C. (2013). Modified social ecological model: A tool to guide the assessment of the risks and risk contexts of HIV epidemics. BMC Public Health, 13(482). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3674938/

Batchelder, A. W., Gonazlez, J. S., Palma, A., Schoenbaum, E., & Lounsbuty, D. W. (2015). A social ecological model of syndemic risk affecting women with and at-risk for HIV in impoverished urban communities. American Journal of Community Psychology, 56, 229-240. doi:10.1007/s10464-015-9750-y

Dyson, Y. D., Mobley, Y., Harris, G., & Randolph, S. D. (2018). Using the social-ecological model of HIV prevention to explore HIV testing behaviours of young black college women. Journal of Associatin of Nurses in AIDS Care, 29(1), 53-59. Retrieved from https://0-www-sciencedirect-com.aupac.lib.athabascau.ca/science/article/pii/S1055329017302625?_rdoc=1&_fmt=high&_origin=gateway&_docanchor=&md5=b8429449ccfc9c30159a5f9aeaa92ffb&ccp=y

Lanier, L., & DeMarco, R. (2015). A synthesis of the theory of silencing the self and the social ecological model: Understanding gender, race, and depression in african american women living with HIV infection. AIDS Patience Care and STD's, 29(3), 142-149. doi:10.1089/apc.2014.0116

Winch, P. (2012). Ecological models and multilevel interventions. Johns Hopkins Bloomberg School of Public Health.