COVID-19 Swiss Cheese Layers of Influence

We know that individuals can have very different disease outcomes for the same disease and that different levels of influences these health outcomes. In other words, it may not be our physiology that determines these outcomes but more likely our social situation. To help us understand this and the relationships we have with ourselves, not only personal relationships but with structures and institutions in our society, we can use a multi-level model. One such model is the Social-Ecological Model that was developed by the Centers for Disease Control and Prevention.

When I first heard the term multi-level model of health I did not think of the social-ecological model but the Swiss cheese respiratory pandemic illustration. This different type of model was originally developed by James Reason (1990) which became to be known as the Swiss cheese model of causation, with the holes in the cheese slices representing errors that if they line up they can lead to an accident. Roberts (2020) explains that recently, this model has been used by experts to explain pandemic defense in relation to SARS CoV-2, the virus that causes COVID-19. The idea is to have a multi-layered defense visualized as cheese slices as no one layer is effective in stopping the spread of new infections. But if you combine many layers – physical distancing, plus staying home if you are sick, plus masks, plus hand hygiene/cough etiquette, plus avoiding touching your face, plus avoiding crowded areas, plus fast and accurate testing and tracing, plus ventilation, plus government policies and support, plus quarantine and isolation, plus vaccines – will significantly reduce the risk (Roberts, 2020). The overall objective is to slow down the disease transmission so that the reproductive number (R) is below 1 and the outbreak would fade away (Mecher, 2021).

Source: Roberts, 2020

One can see how the Swiss cheese respiratory pandemic defense model hits on the multiple factors that might influence ones health from the disease COVID-19. According to the Centers for Disease Control and Prevention (CDC, 2015) the social-ecological model understands health to be affected by the interaction between the individual, the group/community, and the physical, social, and political environments.

Source: CDC. 2015

The first level in the social-ecological model is the individual which includes individual biology and other personal characteristics, such as age, education, income, and health history (CDC, 2015). The Swiss cheese model relies heavily on personal responsibilities and education of that individual. Creditable information/educational campaigns were developed on the importance of personal responsibilities including; physical distancing, masks, hand hygiene and to stay home if you are sick from the NGO’s like the World Health Organization and at the federal, provincial and local levels.

The second level, relationship, includes a person’s closest social circle, such as family, friends and partners, whom all influence a person’s behavior and contribute to his or her experiences (CDC, 2015). These influences can be positive or in the case of misinformation, negative. When COVID-19 hit in 2020 a tidal wave of information, including false or misleading information was being shared. This causes confusion and risk-taking behaviours that can harm ones health. The World Health Organization (2022) termed this onslaught of misinformation as an infodemic.

An infodemic can intensify or lengthen outbreaks when people are unsure about what they need to do to protect their health and the health of people around them. With growing digitization – an expansion of social media and internet use – information can spread more rapidly. This can help to more quickly fill information voids but can also amplify harmful messages.

Are we doing enough as health professionals to battle the seemingly onslaught of misinformation. WHO (2022) suggest infodemic management to systematically use risk and evidence based methods to manage the infodemic and reduce the impact on health behaviours during health emergencies like COVID-19. Initiatives from organizations like ScienceUpFirst (2022) can help. This group of scientists, researchers, health care experts and science communicators share the best available science in creative ways to stop the spread of misinformation.

The third level, community, explores the settings in which people have social relationships, such as schools, workplaces, and neighborhoods, and seeks to identify the characteristics of these settings that affect health (CDC, 2015). Many workplaces and public places like schools, restaurants shut down to slow the spread of the disease. Sick leave and workplaces increasing the ventilation are other examples of community factors and our shared responsibilities.

Finally, the fourth level looks at the broad societal factors that favor or impair health. Examples here include cultural and social norms and the health, economic, educational, and social policies that help to create, maintain, or lessen socioeconomic inequalities between groups (CDC, 2015). Policies like mask mandates, isolation and quarantine measures, developing a vaccine in record time, paid vaccination leave ect. are all examples of societal factors.

Now that we are well into the third year of this pandemic COVID fatigue is settling in. People just want this to be over so we can go back to normal and less and less attention is being paid to all levels of the social-ecological model even as new variants are rearing their ugly heads. Public health measures like mask mandates, isolation requirements, contact tracing and case investigation are being lifted or scaled back. Misinformation is also still running rampant which will have a detriment to the health of the public. This is all weakening our layered defense. To have more positive health outcomes to this pandemic as it is not over and for future pandemics long-term attention to all levels of the social-ecological model is needed to create the changes and synergy needed to support sustainable improvements in health.

References:

Centers for Disease Control and Prevention. (2015, June 25). Chapter 1: Models and frameworks. Centers for Disease Control and Prevention. Retrieved June 20, 2022, from https://www.atsdr.cdc.gov/communityengagement/pce_models.html

Mecher, C. (2021). The Swiss Cheese Layer of Defense. The Public Health Company. Retrieved June 20, 2022, from https://www.thepublichealthco.com/post/the-swiss-cheese-layer-of-defense

Reason, J. (1990). Human error. Cambridge University Press.

Roberts, S. (2020, December 5). The Swiss Cheese Model of Pandemic Defense. The New York Times. Retrieved June 20, 2022, from https://www.nytimes.com/2020/12/05/health/coronavirus-swiss-cheese-infection-mackay.html

ScienceUpFirst. (n.d.). Retrieved July 1, 2022, from https://www.scienceupfirst.com/

World Health Organization. (n.d.). Infodemic. World Health Organization. Retrieved July 1, 2022, from https://www.who.int/health-topics/infodemic#tab=tab_1

World Health Organization. (n.d.). Infodemic. World Health Organization. Retrieved July 1, 2022, from https://www.who.int/health-topics/infodemic#tab=tab_1