Multilevel Intervention Research: Lessons Learned and Pathways Forward

Applied Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Executive Plaza North, Rm 4086, Bethesda, MD 28092-7344, USA.
JNCI Monographs 05/2012; 2012(44):127-33. DOI: 10.1093/jncimonographs/lgs019
Source: PubMed


This summary reflects on this monograph regarding multilevel intervention (MLI) research to 1) assess its added value; 2) discuss what has been learned to date about its challenges in cancer care delivery; and 3) identify specific ways to improve its scientific soundness, feasibility, policy relevance, and research agenda. The 12 submitted chapters, and discussion of them at the March 2011 multilevel meeting, were reviewed and discussed among the authors to elicit key findings and results addressing the questions raised at the outset of this effort. MLI research is underrepresented as an explicit focus in the cancer literature but may improve implementation of studies of cancer care delivery if they assess contextual, organizational, and environmental factors important to understanding behavioral and/or system-level interventions. The field lacks a single unifying theory, although several psychological or biological theories are useful, and an ecological model helps conceptualize and communicate interventions. MLI research designs are often complex, involving nonlinear and nonhierarchical relationships that may not be optimally studied in randomized designs. Simulation modeling and pilot studies may be necessary to evaluate MLI interventions. Measurement and evaluation of team and organizational interventions are especially needed in cancer care, as are attention to the context of health-care reform, eHealth technology, and genomics-based medicine. Future progress in MLI research requires greater attention to developing and supporting relevant metrics of level effects and interactions and evaluating MLI interventions. MLI research holds an unrealized promise for understanding how to improve cancer care delivery.

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    • "The literature has long reported barriers to the implementation of evidence-based preventive health services and cancer screening at the patient-, provider-, clinic-, and health-system levels (Ahmad et al., 2001; Davis and Taylor-Vaisey, 1997; Jhala and Eltoum, 2007; Meissner et al., 2012; Tatsas et al., 2012; Wender, 1993). One-on-one education is effective in addressing provider cancer screening behaviors (Gorin et al., 2006; Sheinfeld et al., 2000; Yeager et al., 1996), however, interventions that address barriers and behavior change through a multi-level, social-ecological approach are most likely to improve cancer prevention and care (Clauser et al., 2012; Meissner et al., 2004; Taplin et al., 2012). This study is unique because it surveys provider practices in addition to the beliefs, attitudes, risks, and facilitators that drive their practice, revealing more about the behavioral environment within which the provider makes their clinical decisions. "
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    ABSTRACT: Objective: Cervical cancer screening using the human papillomavirus (HPV) test and Pap test together (co-testing) is an option for average-risk women ≥ 30 years of age. With normal co-test results, screening intervals can be extended. The study objective is to assess primary care provider practices, beliefs, facilitators and barriers to using the co-test and extending screening intervals among low-income women. Method: Data were collected from 98 providers in 15 Federally Qualified Health Center (FQHC) clinics in Illinois between August 2009 and March 2010 using a cross-sectional survey. Results: 39% of providers reported using the co-test, and 25% would recommend a three-year screening interval for women with normal co-test results. Providers perceived greater encouragement for co-testing than for extending screening intervals with a normal co-test result. Barriers to extending screening intervals included concerns about patients not returning annually for other screening tests (77%), patient concerns about missing cancer (62%), and liability (52%). Conclusion: Among FQHC providers in Illinois, few administered the co-test for screening and recommended appropriate intervals, possibly due to concerns over loss to follow-up and liability. Education regarding harms of too-frequent screening and false positives may be necessary to balance barriers to extending screening intervals.
    Preventive Medicine 04/2013; 57(5). DOI:10.1016/j.ypmed.2013.04.012 · 3.09 Impact Factor
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    ABSTRACT: The complex environmental context must be considered as we move forward to improve cancer care and, ultimately, patient and population outcomes. The cancer care continuum represents several care types, each of which includes multiple technical and communication steps and interfaces among patients, providers, and organizations. We use two case scenarios to 1) illustrate the variability, diversity, and interaction of factors from multiple levels that affect care quality and 2) discuss research implications and provide hypothetical examples of multilevel interventions. Each scenario includes a targeted literature review to illustrate contextual influences upon care and sets the stage for theory-informed interventions. The screening case highlights access issues in older women, and the survivorship case illustrates the multiple transition challenges faced by patients, families, and organizations. Example interventions show the potential gains of implementing intervention strategies that work synergistically at multiple levels. While research examining multilevel intervention is a priority, it presents numerous study design, measurement, and analytic challenges.
    JNCI Monographs 05/2012; 2012(44):11-9. DOI:10.1093/jncimonographs/lgs005
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    JNCI Monographs 05/2012; 2012(44):121-2. DOI:10.1093/jncimonographs/lgs013
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