Rationale for Ecological approach

Tobacco smoking is a multidimensional issue.^{2, 15} It can be viewed from different perspectives such as, at an individual level as a behavioural issue or individual choice, at a community and organisational level as a cultural or social issue and at government level as policy and legislative issue. It involves intricate interrelations among various personal, social and environmental factors.^{14, 15} Billions of dollars are spent by tobacco companies each year on tobacco advertising and promotion.² A significant number of youth’s involvement with tobacco occurs as a result of exposure to such advertising and promotion, which takes this issue out of the isolated bio-psychological domain. Thus an effective control strategy, ideally, should target at multiple levels.

Several Health promotion theories and associated models provide a well explained theoretical framework for effective interventions at different levels such as: Behaviour change and social cognitive theories, community development, capacity building and empowerment models, need/asset based models as well as the social marketing & media advocacy approaches.¹⁴ Nevertheless all of these approaches, and many others, can be effective in different target populations with specific contexts in respect to health promotion. However, as already mentioned, controlling tobacco smoking requires a joined up action and a ‘whole systems’ approach.³ It needs synergy, collaboration and inter-sectorial working.^{3, 2, 15} Thus, an ecological approach provides a roadmap for effective interventions in this domain.

McLeroy’s Ecological Model for Health Promotion

Various ecological models have been proposed to operationalise this approach. The most widely recognised models are Bronfenbrenner’s Model of Human Development⁵, Ecological Model for Health Promotion⁴, The Theory of Triadic Influence⁶, Structural Model of Health Behaviour⁷, Behavioural Ecological Model (BEM)⁸, Social Ecology model for Health Promotion (SEM)⁹ and so on. These models explain and integrate the biological, psychological and wider social, environmental and policy factors that influence a behaviour change. The Ecological Model proposed by McLeroy et al.⁴ is a comprehensive model which encompasses almost all the possible domains and levels that should be considered to design an effective tobacco control intervention. The framework provided by this model includes following multiple levels for intervention^{4 :}

• Intra-personal factors – Knowledge, attitude, behaviour, self-concept, skills etc.
• Inter-personal processes and Primary Groups – formal and informal social network including family, workgroup and friendship networks
• Institutional factors – social institutions with organizational characteristics and formal and informal rules and regulations for operation
• Community factors – relationships among organizations and institutions and informal networks
• Public policy – local, state and national laws and policies

Adopted from Ecological Model for health promotion (McLeroy et al.)

The model also integrates the concept of “reciprocal causation”, used in other theories as well, which means that there is a dynamic inter-relation between the individual and multiple environmental factors which shapes the behaviour.¹⁴ This is quite logical in case of tobacco smoking.

Relevance in Pakistan’s context : Policy, legislation and practical solutions 

Thus, this ecological model can be used to address the tobacco epidemic in Pakistan. Pakistan is a lower middle income to middle income country with a population of 179.9 million.^{10, 11} According to the latest data, 36% of adult males and 9% of adult females are tobacco users¹², and overall smoking prevalence among adults is 23%.¹¹ This high rate of tobacco use is alarming and require well planned, focused and collaborative health promotion interventions based upon the ecological model. Although, Pakistan signed the WHO Framework Convention for Tobacco Control (FCTC) in 2004^{11, 12, 13} and subsequently amended and promulgated national tobacco control laws which banned smoking at public places and public service vehicles as well as enforced restrictions on the advertising campaigns of the tobacco industry¹³, a comprehensive and well planned approach towards effective tobacco control is still lacking. There are loopholes that allow the tobacco giants to exploit an “under-regulated” market.¹³ As with other laws and policies, there is a lack of effective implementation and regulatory machinery in Pakistan. Furthermore, there is a lack of evidence on use of bottom up approaches to tobacco control.¹¹ Major focus has been on the legislative actions and top down approaches.^{11, 13} Thus, ecological approach should be adopted as it provides a blend of bottom up and top down interventions at multiple levels.^{4, 14} Interventions should be designed to target, on priority basis, at Intra-personal, Inter-personal and community level as described by the ecological model while simultaneously keeping the issue of tobacco control in the agenda of the policy makers.

Following suggestive measures can be taken into consideration:

• Individual behaviour change interventions at clinics and hospitals
• Provision and easy access of subsidised Nicotine Replacement Therapies (NRT’s) and other smoking cessation aids at clinics, hospitals and pharmacies
• Awareness and educational interventions at schools, colleges and universities
• Awareness and educational interventions targeted at specific community groups
• Enforcement of the “smoke free air” concept at organisational level
• Effective, forceful and consistent mass media campaigns
• Significant raise on tax on tobacco products
• Direct bans on tobacco advertisement and promotion in any form
• Serious measures should be taken for effective implementation of existing national tobacco control laws

Limitations of Ecological model

Ecological approach and models have been in use for health promotion for several decades.¹⁴ Apart from tobacco smoking, they can be applied to control other complex issues like obesity epidemic, HIV control, Alcohol and drug use.^{4, 7, 14} Policy makers are relying increasingly on multilevel interventions to solve such issues, however there are certain limitations to the ecological model:

• Due to multiple levels of intervention, this model poses methodological challenges in intervention design.^{9, 14}
• It is complex, inter-related and dynamic, which makes it difficult to deploy experimentally.⁹
• In contrast to individual-level psychosocial theories of health behaviour change, which focus on a single element, ecological model is less specific on its discrete individual levels.
• Any intervention or research based on ecological model is much more demanding in terms of resources, outcome measures, statistical sophistication and implementation as compared to behavioural research at a single level.¹⁴
• May pose an ethical issue of relocating the blame of an “individual choice” of a risky behaviour upon wider environmental factors and prevalent policies.¹⁴