Introduction to Special Issue on Social Ecological Approaches to Community Health Research and Action
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- Lounsbury, D.W. & Mitchell, S.G. Am J Community Psychol (2009) 44: 213. doi:10.1007/s10464-009-9266-4
We have the potential to make new, substantive contributions to resolving our most pressing community health problems. However, to do so we must adopt a philosophy of science that is directed towards understanding the dynamic complexity and full contextual reality surrounding these issues. A social ecological approach to science is ideally suited to this challenge. This framework is systems-oriented and defines research problems in terms of structures and processes, generating research outcomes that give insight into the dynamic interaction of individuals with their environment across time and space. Though community psychology is built upon social ecological principles, researchers from other disciplines have also noted its utility and implemented interventions based on this framework. In our introductory article to this special issue on social ecological approaches to community health research and action, we present a brief review of the theoretical foundations of the social ecological approach, present highlights from our selected manuscripts, and conclude with some reflections about the need to build further capacity to conduct effective social ecological research to foster community health and well-being.
KeywordsSocial ecological Community health Research and action
We have the potential to make new, substantive contributions to resolving our most pressing community health problems. However, to do so we must adopt a philosophy of science that is directed towards understanding the dynamic complexity and full contextual reality surrounding these issues. While we enjoy an unprecedented rate of scientific discovery and a seemingly infinite, immediate capacity to share ideas and opinions, our ability to clearly see ‘the big picture’ and to effectively collaborate to address our most complicated problems (e.g., global warming, epidemics, economic instability and poverty) remains limited.
Social ecological research and interventions are ideal for addressing these types of community health-related issues. A social ecological approach is systems-oriented and defines research problems in terms of structures and processes, generating research outcomes that give insight into the dynamic interaction of individuals with their environment across time and space.
The Community Health Interest Group of the Society for Community Research and Action (SCRA) has been discussing various ways in which we, as community psychologists, apply the social ecological framework to our community health research endeavors in an attempt to account for the diverse forces affecting health. We tend to hold both the theories and the methods we use as central to our identity as community psychologists, though in our conversations we are forced to acknowledge the fact that we often work within multi-disciplinary settings, alongside other researchers who are equally wedded to the social ecological framework for investigating and addressing complex health needs in the community.
This recognition of multidisciplinary efforts was the genesis for this special series of articles on social ecological approaches to community health research and action, an activity that would serve multiple purposes for our interest group. First, it created a specific, goal-focused activity that would take our discussion of social ecological health research to a more refined level. Second, it was an opportunity to comparatively examine how researchers across a variety of fields weave the thread of social ecological theory throughout their work. Finally, it was a shameless attempt to draw more ‘community-minded’ researchers into the field of community psychology. This last purpose was achieved via the inclusion of numerous authors who had not previously published within the field, and by inviting the authors whose work is presented in this special issue to present in a series of symposia on the topic at the 12th Biennial Meeting of SCRA held in Montclair, New Jersey in June 2009. From our perspective, we were successful on all counts.
Social Ecological Health Research: A Timely Topic
The utility of social ecological research has received increased attention in recent years from diverse communities of scientists. Notably, the National Institutes of Health (NIH) Office of Behavioral and Social Science Research (OBSSR) and the Centers for Disease Control and Prevention (CDC) have called for health research that links transdisciplinary models in biomedical science (i.e., molecular and physiological causal mechanistic science) with social ecological models that use ‘systems methodologies’ (e.g., social networking, complex adaptive systems analysis, system dynamics modeling) to understand multi-level effects on health outcomes (Mabry et al. 2008). In their strategic prospectus, OBSSR identifies six ecologic-centered domains, namely: (1) gene-environment interactions; (2) environmental effects on physiology; (3) technology, measurement, and methodology; (4) social integration and social capital; (5) complex adaptive systems; and (6) social movements and policy change. New research in these domains is expected to inform innovative strategies that can foster multi-level change and improve population health.
In this article, we present a brief review of the theoretical foundations of the social ecological approach in community research and action, present highlights from our selected manuscripts, and conclude with some reflections on the need to build further capacity to conduct effective social ecological research in order to foster community health and well-being.
Theoretical Foundations of an Ecological Paradigm
Social ecological models are not new to public health or to socio-behavioral science (Darling 2007; McLeroy et al. 1988; Trickett 2009). In community psychology, an ecological perspective on human behavior was a founding tenet of the field (Martin et al. 2004) and our current conceptualizations stem from the rich theoretical foundations built by such luminaries as Lewin (1936), Barker (1964a, b), Barker and Schoggen (1973a), James Kelly (1966), Sarason (1972), Watzlawick et al. (1974), Bronfenbrenner (1977, 1979, 1999), and Weick (1984). Each made major, complementary contributions as they added different perspectives or dimensions to our notion of social ecology, dimensions such as how we define social ecology, ways in which settings influence behaviors, and the dynamic processes of systems change.
Defining Context in Social Ecology
Barker and his colleagues focused their research on the ecological environment, which they defined as “naturally occurring phenomena: (1) outside a person’s skin, (2) with which his molar actions are coupled, but (3) which function according to laws that are incommensurate with the laws that govern his molar behavior” (Barker 1964a, p. 5). Barker described the need to delineate a scope of reference wide enough to capture sufficient context to allow a meaningful assessment of a specified behavior. ‘Ecological units’ comprise the setting, which could be physical, social, biological, or behavioral. Good ecological research is explicit in selecting its units of interest. A valid ecological unit is: (1) self-generated (i.e., occurring naturally without involvement of the investigator), (2) given a specific time–space locus, and (3) internally constrained (i.e., has internal forces that impose patterns on their own internal components). An atom, a person, a family, a classroom, and a town are each examples of possible ecological units of analysis.
Sarason’s (1972) work on creation of settings, which he presented as a marker of social change as well as a strategy to promote social change, further adds to our understanding of context. Sarason’s settings are organizations of people, two or more, and can include something as personal as a marriage or as public as a political revolution. Without fully appreciating a setting’s history, efforts to transform it or to build a new one may unwittingly fail.
The principles of social systems proposed by community psychologist, Kelly (1966), are analogous to biological eco-systems. Kelly identified four key principles of ecology. The first is interdependence, which refers to structural characteristics, whereby a change in one component of a system affects all other components of the system. This concept reflects the reciprocal or mutual influence among components that occurs over time. The second is cycling of resources, which refers to the use and distribution of resources within an eco-system. Environmental biologists would point to the food chain as one example of the cycling of resources, but an equally good social example would be economics and how money flows from one person to another in exchange for goods and services. The third principle is adaptation, the process by which individuals and communities effectively use (or reuse) resources, such as how they change or respond to accommodate a new situation. The last principle is that of succession. Succession is a special case of cycling of resources. Whereas cycling of resources helps us understand the movement of resources into and out of a community, succession refers to the movement of people themselves into and out of a community. Another way of describing the process of succession could be cycling of populations. Succession tends to be characterized as a long-term process, one within which changes occur from one generation to another, and it is often the collective result of adaptation. These four principles represent processes and structures that define the dynamic complexity with an eco-system.
Influence of Settings on Behaviors (and Vice Versa)
Lewin (1936) was an early adopter of the ecological perspective. He endorsed an interactionist concept for understanding how behavior is shaped through processes of nature and nuture, which he summarized in the formula B = f(P|E), ‘Behavior is a function of Person and Environment.’ As a scientist and a European Jew who witnessed firsthand the rise of Nazi Germany, he pondered the capacity for inhumanity among ordinary people. The problem, he argued, was the social environment and the behavior it enabled among those who lived in that place and time (Lewin 1935). Lewin’s formula is a highly aggregated social ecological model. The constructs of ‘person’, ‘environment’, and ‘behavior’ are not well defined, but the concept that individuals are shaped by their environment is clear, and this is Lewin’s main point. Subsequent theorists have continued to elaborate on Lewin’s basic model.
Urie Bronfenbrenner, a student of Lewin’s, is probably most often credited for ecological theorizing, and his work is widely cited whenever the topic of social ecology is evoked. Bronfenbrenner (1979) applied a contextual approach to studying human development, yielding ecological systems theory, which is often summarized with a figure composed of concentric circles representing four types of systems: the microsystem (e.g., the home or classroom of a child); the mesosystem (two interacting microsystems; e.g., the effect of the home on the classroom); the exosystem (external environments which indirectly influence development, e.g., the mother’s place of work); and the macrosystem (the larger socio-economic-cultural context). Contained within each of these systems is the individual (e.g., the child of focus). A fifth system that incorporated the notion of succession came later. Bronfenbrenner referred to it as the ‘chronosystem’, the patterning of environmental events and transitions over the life course, as well as socio-historical circumstances (Santock 2007).
Ecological systems theory treats individuals as active agents who constantly shape, and are shaped by, their environments. Like behavior setting theory, ecological systems theory attends to the way that roles, norms and rules shape behavior, with the objective of understanding developmental processes (Bronfenbrenner 1977, 1979). Bronfenbrenner emphasized the underlying utility of studying behavior as it unfolds in a natural environment, as opposed to a contrived laboratory, where behavior was recorded as an outcome of a controlled setting.
Perception played an important role in Bronfenbrenner’s theory. He embraced phenomenology and the importance of perceptual factors in understanding behavior and human development. How one perceives his or her situation explains behavior motivations. Individual differences should not be ignored, as observational work demonstrated that different environments invoke different behaviors from different people (Bronfenbrenner 1999). Identifying and analyzing patterns of behavior was key to understanding developmental outcomes (Bronfenbrenner 1961). For example, pattern analyses could explain why the same systems generated different outcomes for boys relative to girls.
Barker, also a student of Lewin’s, developed behavior setting theory to explain how settings generate ‘forces’ necessary for their own maintenance and survival. These forces regulate behavior in the setting. Barker and Schoggen (1973b) used the term ‘circuits’ to underscore the notion of a constant feedback that would be experienced between person and setting. First there are program circuits, which are expected behavior patterns based on particular agendas. These circuits differentiate one setting from another. Second are the goal circuits, which refer to the intrinsic purpose of the setting. Deviant-countering circuits, forces which eliminate or reduce deviance from behavior settings, are the third type of setting force defined by Barker. Finally, there are the veto (ejection) circuits which account for the way that a setting is able to jettison a non-conforming member. If a person reaches a particular threshold of person-setting incongruity, they are literally forced away. In short, behavior setting theory identifies structures and processes that interact to control or explain behavior, within a given ecological context. The theory also provides a rigorous method for describing and assessing human behavior at any ecological level, including the community level (Barker and Schoggen 1973b). The approach used to conduct behavior setting assessments, however, involves resource-intensive observational data collection and categorizing.
The Dynamics of Systems Change
From a social ecological perspective, change is quite literally part of the process. Sarason’s (1972) study of creating new settings is ultimately understood as a strategy for introducing innovation and renewal into our social and physical ecologies. As needs change, or as the players in the setting change (such as with Kelly’s concept of succession) the setting itself can be modified. Additionally, Barker and colleagues’ in their concept of ‘circuits’ include a systems-oriented component in their social ecological model by adding a way to identify patterns of behavior over time so as to assess dynamic change.
From an ecological perspective, we need ways of conceptualizing and researching how things change and how they may also stay the same (i.e., be sustained or persist). Paul Watzlawick has written about a theory of persistence and change as a means to studying clinical problem formation and problem resolution (Watzlawick et al. 1974). Watzlawick defines two types of change. First-order change is change that occurs within a given system, which itself remains unchanged, or when a condition (i.e., a particular need or symptom) is addressed but there is no modification of the system as a whole. The existing structures or processes that make up the system remain the same. Second-order change is change that occurs when a fundamental modification is made to the system, when a new structure or process is added to an existing system. Waltzlawick calls this type of change ‘change in change’. We can think of first-order and second-order change in terms of ecological levels of change. First-order change is change that occurs within the confines of a Barkerian ‘ecological unit’. Second-order change is change that occurs as a function of an outside, environmental impact.
These definitions of change have profound implications for social ecological research. Within the context of a particular ecological unit, for example a hospital or a school or some other setting, a problem of concern may persist due to multiple, ineffective ‘first-order’ changes. By stepping back and seeing the environment containing the hospital or school, transformative strategies that create ‘second-order’ change are now visible. When we invoke a second-order change, we are studying the impact of structural interventions, which are often equivalent to attempting change at the community level or higher, changing circumstance for multiple stakeholders. Second-order change is relevant to studies of natural disasters and other large-scale catastrophes (Lovett 1979).
However, in order to affect large change, big initiatives are not always necessarily required. Weick’s (1984) promotion of the notion of ‘small wins’ is implicitly a social ecological construct. Here, big problems are addressed through the cumulative effect of many, tiny contributions from many individuals over time. A small wins approach may be an effective way to put into place policies that can eventually reverse major problems, such as HIV transmission. The key is to motivate small changes in individual behavior that are easy for everyone to make, which in turn would produce overall significant effects. As people recognize these small wins further behavioral change can be promoted, and so on. In this way, a small wins strategy recasts large social problems into smaller, less burdensome or more appealing ones. Small wins capitalizes on a reinforcing process that begets more of the desired action which, over time, can generate substantive improvements in the problem.
Social ecological models also allow (and require) researchers to work with more complexity and added context. For example, Glass and McAtee (2006) have developed a social ecological model that facilitates the study of several logical, but understudied assumptions about health behavior problems. These assumptions include that: (1) a single cause of a specified health problem is unlikely; (2) problems are likely to be effected by combinations of factors at multiple levels of influence; (3) small changes in one or more key factors may, over time, generate large and potentially non-linear influences on the health problem; and (4) both socio-environmental and biological processes are involved in the expression of any given individual’s behavior. This comprehensive model can be used to stimulate social ecological research about virtually any health-related problem or intervention.
Overview of Selected Social Ecological Health Papers
The works selected for this special issue are diverse in purpose, context, questions posed and methods used, but each article applied a social ecological approach to address a salient problem in community health. A review of these manuscripts revealed a number of commonalities, which we assess below.
Relationships Between/Among Ecologic Levels
All fourteen works examined relationships between/among multiple ecologic levels. The typical study presented in this special issue incorporated three levels of analysis, with all manuscripts including reference to the individual level.
A level of analysis was most often defined as a specific type of setting, such as in Kloos and Shah’s article on the impact of housing and neighborhood settings on persons with serious and persistent mental illnesses. They examined how physical aspects of housing and neighborhoods, social environment of neighborhoods, and interpersonal relationships tied to housing allowed for identification of opportunities for health promotion and facilitation of participation in community-based settings.
Freedman identified ‘local food environments’ as an important level of analysis with which to understand dietary health behaviors. Results of her study showed that characteristics of neighborhood food stores were associated with social hierarchies of race, class, and gender, as well as environment. She discusses the utility of a social ecological approach to unraveling the politics of space.
Other manuscripts defined a level of analysis in terms of a social institution, such as ‘the media’ or ‘higher education’. DeBate, Baldwin, Thompson, and colleagues assessed the effectiveness of a school-based intervention to promote physical activity among adolescents and found that the media served as an important linking structure between schools, families, and the community. Similarly, in her article on the potential utility of educational benefits for today’s returning U.S. veterans, Smith-Osborne argues that the institution of higher education can play an important role in helping persons adapt to civilian life, including those with service-connected impairments and disabilities.
One of the selected manuscripts included a sub-individual level (i.e., the genetic level). In her article on childhood obesity, Lytle presents results of baseline data from a sample of youth and parents. She used a longitudinal design to develop a dynamic, multi-level perspective on a child’s home, school and community, linked to hypothesized biological and genetic factors. Her study procedures included a youth blood draw for the purpose of assessing biogenetic correlates of obesity in children. Such studies fit the comprehensive ecological framework for public health research by Glass and McAtee (2006).
Dynamics of Change
All manuscripts explicitly or implicitly described or assessed how, for example, individuals, families, and communities change over time. Kelly’s principles of systems were evident in selected works. Diverse conceptualizations and methods were used to do so, as noted in the following works:
Ta, Marshall, Kaufman, Loomis, Casteel, and Land studied the dynamics of succession using an innovative, area-based approach to assess socioeconomic factors associated with the presence of workplaces belonging to industries reported to be at high risk for worker homicide. They found that the relationship between human/economic capital and block group proportion of high risk industry workplaces was modified by indicators of transience/instability.
Wicke and Silver examined the community-level impact of a single violent event, charting a process of adapting to the storm of negative media and unwanted attention in a Southeast Texas town. They found that specific local social institutions played an important role in helping the community’s residents find constructive ways of adjusting to these pressures, over time.
Hovmand and Ford present a community-level model of domestic violence cases moving through a criminal justice response. They use an innovative method, system dynamics modeling, to evaluate the impact of implementing three interventions—namely mandatory arrest, victim advocacy, and changes in level of cooperation—on two system-level outcomes: improving offender accountability and increasing victim safety. Their model’s simulations illustrate the complex nature of interdependent relationships. Hoffer, Bobashev and Morris also present a community-level model to build a deeper understanding of the dynamics of operation, organization, and structure of a local heroin market. They used agent-based modeling to simulate the behaviors of customers, private dealers, street-sellers, brokers, and the police to examine aggregated patterns of behavior and outcomes over time. Their model is a compelling illustration of the principles of cycling of resources and interdependence.
Finn, Bishop and Sparrow present a dynamic process model of GROW—a mutual help organization for mental health—which examined its impact at the group level, GROW program/community level, and at the individual level. They use GROW findings to assist with the development of a dynamic multi-dimensional process model to explain how mutual help groups can promote positive change. The use of feedback, as an ecological means of understanding change and as a therapeutic device to promote change, is carefully examined.
All manuscripts applied multiple methods (e.g., survey, archival/secondary data analyses, GIS coding, focus groups, key informant interviews) in their analytic approach. Notably, we found that nearly all manuscripts (85%, n = 12) used a least one qualitative method for data collection and analysis.
A study by Chilenski and Greenberg was used to develop a multiple-method measurement strategy to examine associations among community risks, resources, and rates of early adolescent substance use and delinquency in 28 rural and small town communities. Measures included five domains of community risk, four domains of community resources, and population rates of early adolescent substance use and delinquency. Methods combined correlational techniques, Geographic Information Systems (GIS) coding, survey, and in-depth qualitative interviewing. Results of Chelinski and Greenberg’s study showed that several measures of context were significantly associated with community rates of adolescent substance use and delinquency, and different risks and resources appear important for different outcomes, underscoring the need for mixed methods of data collection and analysis.
Most articles reported using a collaborative research strategy, either an academic-community partnership or some form of participatory method, to engage stakeholders, validate outcomes, and/or sustain involvement. For example, the manuscript by Umemoto, Baker, Helm, Miao, Goebert, and Hishinuma illustrates the role of both a partnership with a university and applied principles of community-based participatory research (CBPR) in promoting youth violence prevention. These collaborative approaches to research fostered relationships with diverse community stakeholders, such that health interventions are durable and long-lasting.
Similarly, in their study of the process of implementing a health education curriculum in selected Canadian high school settings, Wharf Higgins, Begoray and MacDonald used a participatory design to build an understanding of health literacy, develop research questions, select data collection strategies, and interpret findings. They describe how applying principles of CBPR fostered more valid, efficient research, as it helped manage the complexities of engaging and navigating diverse school settings. Baffour and Chonody also applied principles of CBPR to examine participants’ definitions of infant mortality, views on the community impact of infant mortality, and strengths and vulnerabilities in the health care service delivery system. Qualitative methods combined with CBPR elicited personal narratives that helped these researchers articulate complexities about the impact of structural, macro-systemic forces on the personal lives of individuals and families in specific neighborhood settings.
We also found that half of the manuscripts described research teams that included two or more types of expertise, drawing from diverse disciplines (i.e., psychology, anthropology, urban planning, social work, engineering, psychiatry, nursing, education, criminal justice, epidemiology and/or public health). For example, Lytle incorporated feedback from a team of scientists with expertise in urban planning, exercise physiology, nutrition, epidemiology, physiologists, and psychology in their study of childhood obesity. Similarly, Ta et al.’s analytic model of industries at high risk for violence in the workplace was the product of collaborative input from researchers in epidemiology, public health and sociology.
Order of This Special Issue
The fourteen manuscripts encompassing this special issue on social ecological approaches to community health research and action can be broadly organized into three substantive themes: understanding and preventing violence in the community; implementing community-focused mental health and substance abuse interventions; and promoting individual health and designing healthy environments. These three categories are used to order the presentation of the manuscripts included in this special issue, as follows:
Understanding and Preventing Violence in the Community
We begin with the school-based violence prevention program by Umemoto and colleagues, followed by Ta et al.’s assessment of community resilience, Wicke and Silver’s case study of collective trauma and community adaptation, Hovmand and Ford’s system dynamics modeling of domestic violence policies, and finally Hoffer et al.’s agent-based modeling of drug marketing dynamics.
Implementing Community-focused Mental Health and Substance Abuse Interventions
Chelinski and Greenberg’s model for assessing community risks, resources, and rates of early adolescent substance abuse leads this category, followed by Finn et al.’s GROW intervention, Kloos and Shah’s housing for persons with severe mental illness, and Smith-Osborne’s assessment of returning veteran’s use of education benefits and mental health needs.
Promoting Individual Health and Designing Healthy Environments
The etiology of childhood obesity and the IDEA project by Lytle is presented first, followed by Debate et al.’s implementation of VERB™, a community-based physical activity intervention for ‘tweens’ and Wharf Higgins et al.’s work on implementing a health literacy curriculum for 10th graders in Canadian high schools. Balfour and Chonody’s study of understanding health disparities from the perspective of African American mothers is featured next. The final manuscript featured is Freedman’s study of local food environments.
Via this introductory article to the special issue on social ecological approaches to community health research and action, we have provided a brief review of the theoretical foundations of an ecological paradigm. Lewin’s formula B = f(P|E) ‘Behavior is a function of Person and Environment’ is the cornerstone to these theoretical foundations. The manuscripts that comprise this special issue work with this premise in a consistent manner. Future social ecological research in community health should explore how individual behavior can, through a cumulative process, affect the environment. For example, how might we foster consciousness-raising interventions that motivate collective action to decrease fossil fuel emissions in a timely, sustainable manner?
Through the work featured in this special issue we identified a number of themes that speak to the utility and the challenges of employing a social ecological approach. Although social ecological research can facilitate the study of relationships between and among multiple ecologic levels and the dynamics of change, to do so well requires a systems-orientation, one that hypothesizes the role of structures and processes that contain the problem of study. However, coming to an adequate conceptualization of these structures and processes may require a significant investment in exploratory or formative research, as most of the research presented here included. This may explain the popularity of qualitative methods used among the works featured. We assert that the utility of using qualitative methods to develop a basic understanding of multi-level, dynamic, interacting structures and processes within an ecosystem cannot be understated. Arguably, qualitative methods and data analyses can more easily generate the contextual data and narrative needed to see the system or the problem of interest than traditional quantitative methods and analyses alone.
The importance of formative research further underscores the utility of building multi-disciplinary, collaborative research capacities. Such capacities can enable us to ‘see the big picture’ with greater clarity while building the long-term relationships needed to conduct multi-level interventions. The role of participatory involvement seems to be integral to effective social ecological research. The majority of the work presented in this special issue demonstrated how effective execution of social ecological health programs required the involvement of multiple stakeholders, such as families, schools, churches, health clinics, and other community-based organizations.
Even before such capacities are in place, a social ecological perspective forces different kinds of research questions, different, that is, from a purely clinical perspective or even a purely public health perspective, where the focus is almost always exclusively on the individual, or the patient, and how he or she can be treated, or cured, or immunized. A social ecological approach demands careful specification of the relationships among the causal processes operating within and across levels, and across orders of change. This approach also demands careful consideration of the unintended consequences of one or more interventions, in the near or long-term future. Assessing readiness for change among individuals, their families, schools, or workplaces is needed (Goodman et al. 1996).
As many of the authors featured here write, a social ecological approach helped them see what was and was not within the scope of individuals’, families’, or communities’ control. A productive social ecological intervention can be used to leverage contextual aspects of the social and physical environment, taking into consideration individual biology and preferences (Huang et al. 2009). According to Glass and McAtee (2006), leverage comes from understanding how ecologic levels are connected by ‘bridges’. They note that ‘bridges’ between levels act as conduits between macro-level forces and the local environment, where behavior ultimately manifests. Cultural norms, social networks, prices, taxes, access to public transportation, stress or poverty are potentially important ‘bridges’. Regulations and policies established at various levels in education, agriculture, transportation, urban development, communications, and trade from local government to international bodies (e.g., the World Bank) are also examples of ‘bridges’.
To summarize, we assert that the problems we face today will require solutions that yield an understanding of the dynamic complexity and full contextual reality that surrounds them. Contemporary research must have the capacity to help us clearly see ‘the big picture’ and to effectively collaborate to address our most complicated problems. We view as a positive step the fact that the social ecological approach appears to be growing in acceptance and use among researchers and interventionists in diverse fields. The popularity of this approach can further link our field and other disciplines in the health sciences, promote deeper understanding of each other, and can foster broader impact of our collective work. As our review of the works selected for this special issue indicated, this is, in fact, a marker of good practice. The insights we gain from our application of a social ecological approach will inform how we can collaboratively disseminate, implement and sustain effective interventions and policies in the coming years.
The authors wish to thank Catherine Kane for serving as our senior editorial advisor and all those who served as reviewers of the manuscripts included in this special issue, namely Holly Angelique, Paul Florin, Chetali Gupta, Richard Jenkins, Sheila LaHousse, Ralph Levine, Pamela Martin, Jon Miles, Robert Mitchell, William Neigher, RaeJean Proescholdbell, Heather Schacht Reisinger, Rebecca Rios, Laura Ryniker, Robert Schwartz, Hayley Thompson and Elisa Weiss. We also wish to thank John Leonard for his expert copy editing of the entire special issue.