Multilevel Model of Health and the COVID-19 Pandemic

Last updated: March 5, 2025

In 1948, the World Health Organization (WHO) defined health as "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity" (World Health Organization, 1948). As the leading global health organization, the WHO’s definition became the standard in the medical community. However, despite significant progress in healthcare over the years, this definition has remained unchanged (Krahn, 2021). This broad definition has faced considerable criticism in modern medicine because "complete well-being" is unrealistic and unattainable.

In contrast, Huber defines health as “the ability to adapt and self-manage in the face of social, physical, and emotional challenges." (Huber, 2011) Contemporary health definitions like Huber’s acknowledge the substantial impact of socioeconomic and community factors on an individual's health outcomes.

Public health uses the multilevel approach to examine how factors beyond individual experiences influence health outcomes within a population (Galea, 2015). Unlike traditional models that focus on biological factors and personal choices, the multilevel model considers external influences at the individual, interpersonal, community, socioeconomic, institutional, and policy levels:

1)        Individual

This category focuses on personal traits, behaviours, and choices that influence health. Examples include genetics, biology, mental health, lifestyle choices, and adaptability.

2)        Interpersonal

This area focuses on how relationships can affect overall health outcomes. Examples include societal pressures, cultural norms, availability of support systems, and expectations from loved ones or peers.

3)        Community

This focus is on the social and physical environments that influence overall health. Examples include access to care (healthcare providers and facilities), housing conditions, neighbourhood safety, and the availability of nutritious foods and recreation for fitness.

4)        Socioeconomic

This category focuses on employment and education. Examples include income and job security, education level, and access to healthcare and healthcare coverage (Canada’s Public Health Agency, n.d). 

5)        Policy/Structural

This category focuses on institutional wide policies to help to achieve favourable health outcomes of a population.

Figure 1: Socio-ecological model framework for prevention (Bendixsen & Yoder, 2017)

Figure 2: Illustrates the various determinants of health across different life stages and levels of influence (Galea, 2015)

Although the multilevel approach introduces complexity to the health models, it helps to create a more realistic model of disease causation (Diez Roux, 2000).  Using this model, public health authorities were able to gain a better understanding of the health outcomes related to the recent COVID-19 pandemic. 

From a public health perspective, the multilevel health model was fundamental in creating a framework to control further spread of the pandemic. Epidemiologists, for instance, relied on this model for contact tracing, which helped identify communities in need of greater outreach to improve healthcare access. This model was used to help create more equitable access to appropriate care.

In 2020, the COVID-19 pandemic led many governments worldwide to implement lockdowns to contain and prevent the virus's further spread. By using the multilevel model framework, the COVID-19 pandemic outcomes were influenced by the following factors:

1)        Individual Level

Public health authorities and ministries of health guided the public in protecting themselves and others from the virus. Recommendations included proper hand hygiene, self-isolation when feeling unwell, testing and vaccination. Additionally, individuals were encouraged to wear masks and follow social distancing measures in public spaces.

2)        Interpersonal Level

Individual interactions played a vital role in controlling the spread of the virus. At the height of the pandemic, Ontario implemented a stay-at-home order prohibiting indoor gatherings with anyone outside one’s household. Individuals could only leave their homes for crucial purposes, such as purchasing food or performing duties as essential workers. Essential workers had to follow workplace guidelines on wearing personal protective equipment (PPE) and maintaining social distance from colleagues, clients, patrons, and patients (Gibney et al., 2022). 

3)        Community Level

Beyond individual actions, community-based efforts played a fundamental role in the pandemic response. Local governments and organizations created testing and vaccination centers, promoted public health campaigns, and provided mental health resources to help individuals cope with the pandemic's social and economic impact. Community groups and charities also organized food drives, donated meals, and distributed PPE to support vulnerable populations.

4)        Socioeconomic Level

Socioeconomic factors significantly influence individuals' ability to follow public health guidelines. Paid sick leave, healthcare, vaccines, and PPE were not equally accessible to everyone. Lower-income individuals often faced barriers such as crowded living conditions, lack of remote work options, and financial constraints that made it challenging to self-isolate (Wachtler et al., 2020). Many essential workers continued to work on-site, increasing their risk of exposure to the virus. The pandemic significantly affected marginalized communities, highlighting the existing health and income inequalities and gaps within our healthcare system (Wachtler et al., 2020) 

According to the Toronto Public Health’s report on the “COVID-19 and the Social Determinants of Health”, marginalized groups including racial minority, newcomers to the country, the unemployed, the unhoused and individuals with lower educations, experienced higher rates of COVID-19 and hospitalization (Toronto Public Health, 2020).  This report highlights systemic healthcare inequities, flagging the need for governments to address the disparities and to improve access to care for individuals in marginalized communities.

5)        Policy/Structural Level

Government policies play a key role in shaping health outcomes. Measures such as financial aid programs (Canada Emergency Response Benefit, CERB, in Canada), rent breaks, and business subsidies helped mitigate economic hardships (Government of Canada, n.d.). Public health mandates, including mask-wearing policies, vaccine distribution plans, and quarantine requirements, were implemented to control the virus.

During the peak of the pandemic, healthcare institutions faced overwhelming challenges, including a shortage of PPE, a continuous influx of critically ill patients, limited availability of intensive care beds, and severe staff shortages leading to burnout (Gibney et al., 2022).  To help individuals stay at home, institutions around the world expedited the use of virtual care.

Conclusion:

The multilevel model of health is a framework that contrasts with traditional models, which emphasize individual choices and genetics. By adopting this model, public health authorities during the COVID-19 pandemic were able to incorporate wider social and institutional factors affecting the crisis. This approach was instrumental in creating interventions that reduced virus transmission, alleviated pressure on strained healthcare systems, highlighted disparities in healthcare access, and supported various community groups.

References:

1.        Bendixsen, C., & Yoder, A. M. (2017). Socio-ecological model framework for prevention [Figure 1]. In Using the socio-ecological model to frame agricultural safety and health interventions. ResearchGate. https://www.researchgate.net/profile/Casper-Bendixsen-2/publication/318840832/figure/fig1/AS:543633808281600@1506623808268/Socio-ecological-model-framework-for-prevention-centers-for-disease-control-Available_W640.jpg

2.        Canada’s Public Health Agency. (n.d.). Social determinants of health. Kids New to Canada. https://kidsnewtocanada.ca/uploads/documents/Social_Determinants_of_Health.pdf

3.        Diez Roux, A. V. (2000). Multilevel analysis in public health research. Annual Review of Public Health, 21(1), 171–192. https://deepblue.lib.umich.edu/bitstream/handle/2027.42/55393/Diez%20Roux%202000%2021.pdf?sequence=1

4.        Galea, S. (2015). The determination of health across the life course and across levels of influence. Boston University School of Public Health. Retrieved from https://www.bu.edu/sph/news/articles/2015/the-determination-of-health-across-the-life-course-and-across-levels-of-influence-2/

5.        Gibney, R. T. N., Blackman, C., Gauthier, M., Fan, E., Fowler, R., Johnston, C., Katulka, R. J., Marcushamer, S., Menon, K., Miller, T., Paunovic, B., & Tanguay, T. (2022). COVID-19 pandemic: The impact on Canada’s intensive care units. FACETS, 7(1), 144–165. https://doi.org/10.1139/facets-2022-0023

6.        Government of Canada. (n.d.). Apply for the Canada Emergency Response Benefit (CERB). https://www.canada.ca/en/services/benefits/ei/cerb-application.html

7.        Government of Ontario. (2020). Rules for areas in stage 3 (O. Reg. 82/20). https://www.ontario.ca/laws/regulation/200082#BK16

8.        Huber, M. (2011). HEALTH: HOW SHOULD WE DEFINE IT? BMJ: British Medical Journal, 343(7817), 235–237. http://www.jstor.org/stable/23051314

9.        Krahn, G.L et al. (2021). It’s time to reconsider how we define health: Perspective from disability and chronic condition. Disability and Health Journal, 14(4). https://doi.org/10.1016/j.dhjo.2021.101129

10.  Toronto Public Health. (2020). Social determinants of health and COVID-19: Summary of early evidence and implications for policy and action. City of Toronto. https://www.toronto.ca/wp-content/uploads/2020/07/956b-SDOHandCOVID19_Summary_2020July1.pdf

11.  Wachtler, B., Michalski, N., Nowossadeck, E., Diercke, M., Wahrendorf, M., Santos-Hövener, C., Lampert, T., & Hoebel, J. (2020). Socioeconomic inequalities and COVID-19 - A review of the current international literature. Journal of health monitoring, 5(Suppl 7), 3–17. https://doi.org/10.25646/7059

12.  World Health Organization (WHO). (2021). Social Determinants of Health and Health Equity. https://www.who.int/health-topics/social-determinants-of-health