title: The ecological approach in health promotion programs: a decade later.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  METHODS
  Health care facilities, schools, workplaces, living environments, and public environments were represented in program descriptions.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Work and Social Psychology, Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands. g.kok@psychology.unimaas.nl
authors.forename: Gerjo
authors.initials: G
authors.lastname: Kok
authors.forename: Nell H
authors.initials: NH
authors.lastname: Gottlieb
authors.forename: Matthew
authors.initials: M
authors.lastname: Commers
authors.forename: Chris
authors.initials: C
authors.lastname: Smerecnik
mesh_terms: D003159:Community-Institutional Relations; D004463:Ecology; D004779:Environment Design; D006293:Health Promotion / Q000379:methods* / Q000458:organization & administration / Q000706:statistics & numerical data; D006801:Humans; D007398:Interpersonal Relations; D007407:Interviews as Topic; D008962:Models, Theoretical; D009426:Netherlands; D015397:Program Evaluation; D012931:Social Environment; D012944:Social Support; D014481:United States