Exploring the Landscape of Eco-Mapping in Health Services Research: A Comprehensive Review

Health services research is important in improving health systems’ and providers’ efciency and efectiveness. Tis may require health services to intervene at an individual and community level to address people’s complex social issues. An important issue is social connections, which have been identifed as a social determinant of health and can help bufer stressful life events. Social support networks can be visualized using eco-maps, a tool that originated in child welfare practices and has been adopted widely by clinicians and researchers. Tis paper aims to understand where and how eco-maps have been used in health services research. To answer the research questions


Introduction
Health services research is relied on to improve the efciency and efectiveness of health professionals and healthcare systems [1,2].To further the health and well-being of populations [3], efective health systems and healthcare delivery must operate within the social context of individuals and communities [4].Tis may mean recognizing and intervening at the individual and community level to address social challenges [5].Te ecological systems theory captures this complex interplay between individual, community, and societal factors and supports application to systems-thinking more broadly [6].
Only recently has the status of one's social connections been recognized as a social determinant of health [7,8].As an umbrella term, social connection represents how we can connect to others socially through physical, behavioural, social-cognitive, and emotional means [9].Positive interpersonal relationships can bufer stressful life events by mitigating their negative impacts [10,11].Notably, support from family and friends and meaningful engagement in social activities and relationships can improve longevity and physical and cognitive capabilities [10].Assessing social connections and networks to determine population risk [9] or intervening to strengthen those relationships can signifcantly reduce psychological distress [12].Tere is also a strong push for adopting a "whole-of-systems" response to connecting and reconnecting people to address widespread social isolation [13].
Social support networks, when visualized, can provide rich information about the interplay between the relationships of individuals and families with other systems [14].One tool used to diagram relationships is the eco-map.Ecomaps originated in the 1970s as an assessment tool to help workers in public child welfare practice examine the needs of children and families [15].Tey are graphic illustrations of individuals or family units shown in the center of a circle.Outer circles within concentric circles formed around the center represent the sources of connection to that person or family, refecting less intimate relationships moving outward [16].Lines joining the outer circles to the central circle are denoted in specifc ways to represent the nature of the relationships.For example, a solid or thick line represents a critical or strong connection, a dotted line means a tenuous connection, and a jagged line could signify a conficted connection [15].Lines with arrows indicate the direction of resources, energy, or interests [15].See Figure 1 for a sample eco-map drawing.With the diagram's representation of familial and environmental relationships, it is possible to evaluate the range of, or lack of, support and assistance available to people and families [17] and communities [18].
In recent years, practitioners, researchers, and decision makers have utilized eco-maps in various ways in health services research [15,19,20].Notably, researchers with clinical expertise have used eco-maps to generate research data within a study context [16].Terefore, as an assessment, planning, and intervention tool, eco-mapping spans, but is not limited to, end-of-life care [21,22], discharge and community reintegration planning [20,23], and community asset mapping [18].Given the increasing attention on social connections as a public health priority [9], eco-maps could be leveraged through research to capture gaps and opportunities in health services and supportive care networks [17].Mounting evidence of eco-mapping used to analyze support networks demonstrates its practicality [24,25]; however, a synthesis of what is known about eco-mapping in the extant health services literature is yet to be done.A scoping review is warranted to understand for what purpose and how eco-mapping has been used broadly in health services research.
1.1.Objective.Tis paper aims to understand where and how eco-maps have been used in health services research by addressing the following research questions: (1) What are the characteristics (i.e., study design and methods, setting and sample population, and research aims) of eco-mapping studies in health services research?(2) What methodological considerations have been reported in the literature (i.e., use and construction of eco-maps, analysis, and challenges) for using ecomaps in health services research?(3) What are the implications of eco-mapping on health services?

Methods
Tis scoping review was completed following the Joanna Briggs Institute (JBI) methodology for best practices and scoping reviews [26,27].Our approach aligns with JBI's fve stages: identifying the research question, identifying relevant studies, study selection, charting the data, and collating, summarizing, and reporting the results.Tis review was registered on 13 December 2022 with the Open Science Framework (OSF) registry (registry DOI: https://doi.org/10.17605/OSF.IO/GAWYN), and the study protocol was previously published [28].Tis study did not require a research ethical board approval as it did not involve human or animal subjects.Findings are presented according to the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews" (PRISMA-ScR) Checklist [29].

Stage 1:
Identifying the Research Question.It is wellrecognized that placing people and communities at the center of their health and care is vital to how services are designed and delivered [30].However, it is unclear how ecomapping, an approach for visualizing social networks, could support well-planned, integrated health services.In the current study, we are conducting a scoping review to report the fndings and a range of research concerning ecomapping in health service research and potential opportunities for future research.To support our goal and knowledge gap, the study authors identifed the following research questions: (

Population.
As the review focused on using ecomapping more broadly in health services research, we included studies focused on any clinical population or study participants to ensure a broad scope of the literature.
2.5.Concept.Te core concept involved applying ecomapping/eco-map(s) in research studies.Eco-maps were defned as visual illustrations with the individual or family unit placed at the center, surrounded by relationships they identifed as part of their social environments [15,32].
2.6.Context.Since a globally accepted defnition of health services research does not exist, the Canadian Institute of Health Research (CIHR) defnition was chosen given its application to other scoping reviews and familiarity with the study authors [33,34].CIHR is Canada's federal funding agency for health research.Te agency defnes health services research as research to improve the efciency and efectiveness of health professionals and the healthcare system through changes to practices and policy.Health services research consists of a multidisciplinary approach to the scientifc inquiry of how social factors, fnancing systems, organizational structures and processes, health technologies, and personal behaviours afect access to health care, the quality and cost of such care, and ultimately the public's well-being [2].We excluded studies outside the scope of health services research, such as environmental [35] and educational [36,37] research.Health & Social Care in the Community  Several reviewers (MS, HS, SB, KS, LW, and BA) then independently extracted data from the included studies using Covidence software [31].Relevant categories for the data form consisted of author, year of publication, country of origin, study purpose/aim, study design, data collection method(s), study participants, sample size and setting, analysis, application of eco-mapping, rationale for use and stated benefts and challenges, study fndings, and implications for health services.Te frst author (MS) verifed the extracted data for accuracy and completeness.

Stage 5: Collating, Summarizing, and Reporting the
Results.Once collated into an Excel spreadsheet for analysis, the data were summarized using a basic numerical account to summarize the studies, followed by JBI's scoping review guidance recommendation of basic qualitative content analysis [26].One researcher (MS) used a combination of directed content analysis (deductive analysis) [38], drawing on the review objectives and the concepts of Population (i.e., clinical population), Concept (i.e., visual illustration, social environment, and family unit), and Context (i.e., hospital, mental health, and primary care) defned a priori to identify preconceived codes and inductive conventional content analysis [38].For the latter, the researcher (MS) read the extracted data and coded additional codes (i.e., support network, care network, family function, etc.).Codes with similar concepts were grouped to form categories, contributing to the formation of methodological considerations.
Te directed content analysis leverages existing research to derive and apply categories, while inductive captures emergent categories [39].

Results
Te screening process following the PRISMA 2020 framework [40] for reporting scoping reviews is illustrated in Figure 2.  (2016)(2017)(2018)(2019)(2020)(2021)(2022).Te health discipline most reported in conducting the research by identifying the researcher(s) afliation was nursing in forty-three studies with less representation by social work (n � 6).Te remaining studies were either situated in the occupational therapy feld (n � 1) or included several disciplines and thus were considered interdisciplinary (n � 4).Finally, 23% (n � 16) of the studies did not report the discipline or discipline reporting needed more clarity.

Study Characteristics.
For research question one, we examined the characteristics of the included studies in more detail below, covering the reported study design and data collection methods, study setting and the sample, phenomena of interest, and implications for health services.

Methodological Considerations.
In the following section, we summarize what methodological considerations have been reported in the literature (i.e., use and construction of eco-maps, analysis, and challenges) for using eco-maps in health services research.In doing so, we identifed several broad ways the eco-maps were applied in the included studies.Researchers' application of eco-maps was credited with optimizing data visualization for the participants and the researcher and as a data organizational tool.For some authors, eco-maps also enhanced clinical assessments and interventions and seemed to optimize communication between researcher and participant.

Uses for Eco-Maps
(1) Data Visualization Tool.Using the eco-mapping tool enabled researchers to develop a "visible" [21] 3).Te ability to describe the varying dimensions of relationships in detail gave researchers a rich understanding of how participants positioned themselves in relational landscapes [80].For practitioners, eco-mapping was valued for its ability to visualize support networks from the perspectives of families and individuals [87,93].
(2) Data Organization and Comprehensiveness Tool.Ecomaps were used successfully to support data collection in the context of social networks and relationships for a range of populations [17,63,68,87].We observed how eco-maps supported deep exploration and organization fndings during the interview process [21,51,53,54,57,67,68,80,92,93,97] and triangulate multiple data sources to reinforce data comprehensiveness (i.e., photos, text, and observations) [17,63,90].In line with data visualization, some authors also referred to eco-maps ability to "synthesize" the data for greater visual impact [44].Mercier and Harold [67] noted how eco-maps collect and organize data from an eco-systemic perspective.In this study, eco-maps were used to capture the sociocultural context of participants' lives and structure the interview process [67].At a community level, Seah et al. [18] used eco-mapping to organize community aging assets, enabling older adults to understand access to their local aging assets.
Te CFAM is organized into the genogram and the eco-map tools, and there is a heavy emphasis on identifying strengths and weaknesses with the expectation of proposing interventional measures for families.Many authors suggested that through eco-mapping and understanding the family dynamics, bonds, and available sources of support [21,45,48,75,78,83,85,88,95,99,100,102], healthcare professionals can tailor their communication approaches and information [21,22].With consistent updates, the tool was recognized as a helpful reminder of the available social resources for patients and family members [59,76,98,105].
Several authors suggested that eco-maps ofer a systematic way of assessing and organizing resources that could be reviewed with patients and families periodically [59,61].
Nurses and allied healthcare providers were often suggested to be well-positioned to assess family situations using ecomaps to establish appropriate interventions to support care [47,75,76,91,94].Other authors used eco-mapping to "measure social support" of family members and individuals in the wider context in which they exist [63,99].
(4) Engagement and Refective Tool.A few authors noted that co-constructing meaning and negotiating the creation of the eco-map between individuals and family members provided useful research data [17,57,58] and contributed to the meaningful involvement of people and a trusting relationship between participants and researcher [17,57,79].Relationally, eco-maps strengthened the rapport between individuals and families and those facilitating the map [56,71], thus accelerating the ability to intervene clinically if necessary [101] or to refect the participants' world view through the eco-map [17].Authors of one study stated that eco-maps illuminated and "verifed a shared perception" of the participants' family functioning [46], thus reinforcing the researcher-participant connection.Two studies highlighted the value of refection encouraged by eco-maps [105] over the imposition of research preconceptions on the data collection process [57].

Constructing Eco-Maps
. Some of the authors ofered details as to how the eco-maps were made.Many described that the eco-map involved a circle in the middle with the individual's name or a dyad (patient and carer) [97], surrounded by outer circles representing the support or "subjects" (e.g., family, friends, community, health, and work) in their everyday lives [21,55,86,89,90,92,95,96,99,103].
Health & Social Care in the Community Similarly, a minimalist eco-map consisting of the inner circle and six blank outer circles was meant to facilitate the inclusion of persons with dementia [57].Te "Circles of Care Eco-map" ensured that the patient's chosen caregiver occupied an inner circle, and the map highlighted both formal and informal services [22].Last, authors of one paper provided extensive instructions on how they created a digital prototype of an eco-map [98].

Identifed Challenges.
While primarily the benefts of eco-maps were reported, several authors mentioned challenges.For example, challenges included time constraints in completing the tool [104], pressure to maintain workfow, and potential difculties in addressing issues raised by participants [98]; however, some studies reported the time required to complete the tool (i.e., in about two minutes) [62].Several authors suggested eco-maps' downfalls as the lack of exhaustive fndings [18] and researchers sensing discomfort in the participants and interviewers with the tool [21].

Implications for Health Services.
Findings from the studies indicated several implications for health services related to assessment and patient and family engagement.A prominent suggestion was ensuring individuals and families access the necessary supportive relationships to improve their quality of life and well-being.Tis could be done through facilitative conversations about care expectations of social support networks [42,52,73].Similarly, some authors advocated for families' active involvement in assessments and treatment planning, like eco-maps, to improve patients' self-management behaviours, meet complex care needs, and assist with discharge planning [22,46,49,58,62,71,82,88,89].
According to six studies, applying eco-maps to emphasize family strengths and resources can increase opportunities for healthcare providers to achieve positive outcomes [58,79,101,105], promoting closer bonds, autonomy, and acceptance in families [83,86].For example, in light of fnancial costs associated with illness, one paper suggested that providers could use the eco-map to specifcally identify unpaid support to address expenses by asking, "How can Uncle Charlie be of help?" [22].
Some study authors reported their fndings on a broader system and cultural level.For example, the fndings from several studies highlighted the need for intersectoral and multiprofessional action by healthcare providers to identify existing and potential resources within larger networks of health and social care [22,50,63,85].At the same time, another study asked about the dominant culture supporting minority cultures to achieve a sense of belonging [53].Last, several studies referred to public health and social policies and initiatives to support more vulnerable populations like older adults, children with chronic conditions, and employed mothers by bolstering "health promotion strategies" and resources [48,68,85,102].

Discussion
Tis review aimed to understand where and how eco-maps have been used in health services research, service design, and delivery.We identifed 70 studies employing ecomapping in the context of health services research published before January 16, 2023.We discovered that thirty-six studies were published in the past six years, and most studies originated from Brazil and relied on qualitative data.Te recent increase in the scientifc output featuring ecomapping compared to prior years may respond to the heightened focus on social connectedness as a social determinant of health [5].Eco-mapping as an organizing framework ofers a simple way of assessing the structure and functions of personal and familial social networks.Similarly, the high publication rate in Brazil could be due to the country's widely adopted use of the Calgary Family Assessment Model, which includes the eco-map tool [107].
As a simple pen-and-paper tool ofering a "bird's eye view" of the whole individual or family situation, this scoping review has proven the efectiveness of the eco-map across various research objectives, populations, and settings.Te eco-map's value, according to many of the included studies, was its visual presentation of the data in the form of the social support network and the strength of these relationships for individuals and families.Terefore, some individuals who are nonverbal, younger participants, or those who fnd verbal expression challenging may fnd engaging through the eco-map benefcial to their participation in health services planning and research [24,108].However, emerging research is exploring the validity and reliability of the tool compared to established social support measurement scales (i.e., the Multidimensional Scale of Perceived Social Support) [109].Our review found that ecomaps' hard-copy format was sometimes created using computer software [51,52,65,84,91] and, in one example, integrated into a web-based application being studied to support families of those with an acquired brain injury [105].Te creation of an electronic eco-map in primary care has been referred to in other work [110].Tis holds promise for designing a user-friendly eco-map that clinicians can easily update.
Our scoping review also found that the eco-map tool tended to be positioned as a data collection strategy for documenting social support networks and their nuances at microlevels.However, the potential for large-scale impact was captured in the "eco-map of aging assets," which acted as a repository of resources among older adults living in the community [18].As an example of large-scale impact, the asset eco-map could be used as an assessment framework to assist community members in understanding, accessing, and maintaining community-oriented assets.Te fnding aligns with other eco-mapping literature that informed large-scale awareness and action on public health measures (i.e., virus transmission and TB surveillance and acquisition of medicine) and health services planning [51,[111][112][113].While there is more interest in patient engagement in health services research involving active and meaningful collaboration between researchers, patients, and families [114], there is limited awareness of tools to support this process [33].Our review showed that eco-mapping was often deployed to support conversations between academics and participants about their social support networks or access to support and resources [21,53,54,57,80,97].However, the eco-map has not traditionally been considered a tool for increasing engagement in health services, unlike other areas outside health care that have used it for "creative engagement" [115,116].
(1) Research Implications.Several important health services implications should be considered from the included studies.Social support denoted in an eco-map does not guarantee the provision of support [42,58,97].However, the dialogue to create an eco-map could facilitate conversations about care expectations [42], identifcation of vulnerable points or risk factors [47,64,66,74,94,103], and actions to improve family and individual functioning (e.g., selfmanagement behaviours and disease management) [41, 44-46, 55, 58, 65, 98, 101, 104].It may also enable healthcare professionals and researchers to understand better family dynamics and their cultural and structural factors to tailor communication and support strategies and initiatives at the individual and public health levels [21, 49, 57, 68, 72-74, 84, 87, 95, 100-102].Many studies also highlighted the importance of understanding available resources supporting the patient and the family unit to meet the needs of various populations [17, 18, 22, 49, 50, Health & Social Care in the Community 53,58,70,92,93,97].Finally, several studies commented on family oriented approaches to regular assessments and interventions depending on the area of focus that eco-mapping could reinforce (e.g., caring for older adults, children with visual impairment, etc.) [62,69,75,77,79,81,82,88,89,99,105].Despite strong evidence indicating the association between high social support and better health outcomes [117], challenges persist in developing strategies and initiatives that target social network size and quality [118].Eco-maps can identify existing resources and help uncover needed support and barriers to obtaining support [23].Examining these social networks could also support service integration based on individual and community needs [6] at meso-and macrosystem levels.

Study
Limitations and Future Directions.We predefned health services research based on a widely used and accepted defnition by CIHR [2], and additional sources were not searched.We may have included additional studies if we used another defnition or additional data sources.While data extraction was performed independently by several reviewers and verifed, only one researcher analyzed (i.e., coded and categorized data); however, all study authors reviewed and accepted the fndings.Tere were also abundant studies from Brazil, with fewer from other parts of the world.Tese studies reported on the use of eco-maps within a particular healthcare context, and as such, there was less evidence relating to applying the tool in other jurisdictions.While the setting of the application may not afect the use of the data yielded by the eco-map, further research in diferent countries may establish better transferability of fndings to other health systems.

Conclusion
Tis scoping review has contributed to the evidence on the application of eco-mapping in health services research, demonstrating the promise it brings to addressing vulnerable populations and system transformation.However, a signifcant gap remains in the knowledge and use of ecomaps in identifying population service and resource gaps and how to bridge the knowledge-to-action chasm better.Further exploration is needed to examine how to optimize the application of eco-mapping in the health services context, including generating guidelines, templates, or instructions for implementation.Terefore, addressing this gap is vital for ensuring eco-mapping informs future service design and policy changes.
Any clinical population or study participants (i) None Concept (i) Application of applying eco-mapping/eco-map(s) in research studies defned as visual illustrations with the individual or family unit placed at the center, surrounded by relationships they identifed as part of their social environment (i) Application of a similarly termed tool, such as "ecograms" Context (i) Applied in health services research defned as research to improve the efciency and efectiveness of health professionals and the healthcare system through changes to practices and policy (i) Non-health services research context, such as education or environmental research Characteristics (i) Published in English (i) Non-peer-reviewed (ii) Contains primary data (ii) Paper type (i.e., dissertation, commentary, and conference abstract) (iii) Any study design 4 Health & Social Care in the Community 2.7.Stage 4: Charting the Data.Te extraction form was piloted by two authors (MS and HS) and expanded to include additional details.
Providing a visual of resources, social support networks , and the strength of these relationships for individuals and families.Supporting the synthesis and organization of fndings.Supporting patient assessments and interventions as part of the Calgary Family Assessment Model.Contributing to meaningful engagement of research participants.

Table 1 :
Inclusion and exclusion criteria.