摘要：Multilevel interventions can be uniquely effective at addressing minority health and health disparities, but they pose substantial methodological, data analytic, and assessment challenges that must be considered when designing and applying interventions and assessment. To facilitate the adoption of multilevel interventions to reduce health disparities, we outline areas of need in filling existing operational challenges to the design and assessment of multilevel interventions. We discuss areas of development that address overarching constructs inherent in multilevel interventions, with a particular focus on their application to minority health and health disparities. Our approach will prove useful to researchers, as it allows them to integrate information related to health disparities research into the framework of broader constructs with which they are familiar. We urge researchers to prioritize building transdisciplinary teams and the skills needed to overcome the challenges in designing and assessing multilevel interventions, as even small contributions can accelerate progress toward improving minority health and reducing health disparities. To make substantial progress, however, a concerted and strategic effort, including work to advance analytic techniques and measures, is needed. Investments in biomedical, social, and behavioral sciences have greatly expanded knowledge of the etiology, prevention, detection, and treatment of many diseases, and many of these advances have contributed to improved population health. Nonetheless, not everyone has benefited equally from scientific development and medical advancement, 1 and strategies to reduce socioeconomic and racial/ethnic disparities frequently remain elusive. In large part, this is because the factors that underlie disparities are wide ranging and multifaceted; these factors encompass every socioecological level, including individual, interpersonal, community, and societal (in this supplement issue, Alvidrez et al. describe the National Institute on Minority Health and Health Disparities [NIMHD] framework). 2 NIMHD defines a health disparity as a health difference that adversely affects disadvantaged populations on the basis of 1 or more of the following health outcomes: 1. higher incidence or prevalence of disease, 2. earlier onset or faster progression, 3. poorer daily functioning or quality of life, 4. premature or excessive mortality, and 5. greater global burden (see Duran and Pérez-Stable in this supplement issue). 3 Health disparities are generally embedded in social or structural determinants of health, which cannot be effectively addressed at the individual level alone (see Brown et al. in this supplement issue). 4 Efforts to reduce disparities and promote health equity must therefore address the dynamic interplay of multiple levels of influence to be effective. 5 Indeed, social characteristics such as race/ethnicity and socioeconomic status are highly interconnected with critical influences across levels, such as the physical environment, access to health care services, and psychosocial experiences rooted in socioenvironmental factors (e.g., discrimination, victimization, stress). A critical limitation of many interventions targeting minority health and health disparities is that they have tended to focus on single or individual-level factors. As a result, the National Institutes of Health has called for more research employing a multilevel approach to address the health needs of disadvantaged populations. 6 To respond to this call, we must consider approaches for systematically designing and assessing the efficacy of multilevel interventions in these populations. This will enhance researchers’ ability to develop efficient and effective approaches, identify multilevel causal factors contributing to intervention efficacy, and understand their dynamic interactions within and across intervention levels. Progress is being made in this regard, with a growing body of work demonstrating the promise of multilevel interventions for improving health outcomes in disadvantaged populations and addressing health disparities. 7,8 However, designing and assessing multilevel interventions continue to pose substantial methodological and data analytic challenges 9 that may hinder their use. Some challenges may be universal and occur in all types of multilevel interventions, whereas others are specific to interventions addressing minority health and health disparities. Continued growth in the use of multilevel interventions to reduce health disparities depends on the ability of researchers to effectively address the challenges of designing and implementing rigorous outcome assessments. To facilitate the adoption of multilevel interventions to reduce health disparities, we outline areas of need to fill operational challenges in the design and assessment of multilevel interventions: both universal challenges inherent in all multilevel interventions and challenges specific to interventions for minority health and health disparities (see the box on this page). Recommendations on Research Priorities for Multilevel Interventions to Reduce Health Disparities Methodological Considerations Research Priorities Framework and design Develop and evaluate novel and systemic theoretical frameworks and models that can account for interactions among multiple levels and that include socioeconomic and environmental determinants of health disparities. Integrate conceptual frameworks addressing issues specific to minority health and health disparities into multilevel intervention research. Develop new metrics that incorporate elements of existing theoretical frameworks that can be applied to multiple levels to understand independent and interactive effects of intervention components and confounding variables as well as elements such as fit and longevity of interventions in health disparities–relevant contexts. Evaluate the effectiveness of various multilevel research designs (e.g., randomized controlled trials, quasiexperiments, natural experiments) to assess potential for determining mechanisms that are associated with health disparities in populations of interest. Constructs, measures, and intervention components Develop reliable and culturally and linguistically appropriate constructs and measures to examine intervention components at each level to provide a comprehensive understanding of intervention outcomes on health disparities, and evaluate new and existing measures among minority and underserved populations. Identify specific, individual intervention components (e.g., through pretrial designs, multiple iterative pilot tests) that are active in shaping outcomes and have been shown to produce reductions in health disparities. Assess interactions between intervention components across levels to identify situations in which they either impede each other or produce synergistic effects to allow effective replication and scaling. Statistical and analytic approaches Employ the requisite advanced analytical tools (e.g., hierarchical linear modeling, structural equation modeling) and aggregation approaches to properly detect health outcome changes across levels, potential interactions between factors, delayed effects, and intervention effectiveness to reduce health disparities. Analyze process variables to better understand the causal pathways and mechanisms that affect intervention outcomes, contextual factors associated with variation in outcomes, and ways to optimize intervention effects to reduce health disparities. Analyze the temporal effects of policies in the socioecological context and how they influence outcomes across all levels, as well as their impact on reducing health disparities. Open in a separate window We argue that overcoming both types of challenges is essential for promoting the use of multilevel interventions to address minority health and health disparities. Rigorous approaches to trial design and assessment will improve the utility of multilevel interventions by identifying mechanisms or pathways to effectively reduce health disparities. To advance the field, we discuss areas for development that address overarching constructs inherent in multilevel interventions, with a focus on application to minority health and health disparities. This approach provides the most useful information to researchers because it integrates information related to health disparities research into the framework of broader, more familiar constructs..
