The ecological approach in health promotion programs: a decade later.

PURPOSE: Present a 10-year update of the ecologic model of health promotion published by Richard et al. in the American Journal of Health Promotion in 1996. APPROACH: We adapted and simplified the model by leaving out settings, focusing on levels, and incorporating interpersonal and individual levels and agents that are in control of environmental conditions.
SETTING: Health care facilities, schools, workplaces, living environments, and public environments were represented in program descriptions. PARTICIPANTS: Forty-three program coordinators responsible for 47 programs were interviewed in the United States and The Netherlands.
METHODS: A systematic interview protocol elicited general program descriptions and relevant aspects of the ecologic approach. Program aspects from written reports were coded by the authors into levels, interventions, targets, and strategies.
RESULTS: The programs had 234 strategies and 276 targets, with a mean of 2.15 levels. Twenty-seven distinct intervention strategies were identified, with the most common being modification of an organization to which the at-risk individuals belong, followed by policy and community changes.
CONCLUSION: Our data fit the ecologic model and our adaptations and indicate that over the past decade health promotion practice may have changed to include more multilevel programs. Systematic analysis of program strategies within and across environmental levels allows better understanding of the social ecology of health-related behavior and potential leverage points for change.