Multilevel Interventions

Theorizing About and Conceptualizing Multilevel Interventions

Multilevel interventions have structural underpinnings in systems theories. Specifically, ecological frameworks are frequently used to conceptualize health-related MLIs. The concept of intervention “levels” stemmed from Urie Bron-fenbrenner's ecology of human development, in which he described human behavior as nested within multiple systems of influence, contending that each system can have direct or indirect influences on each other. He discussed three levels of influence on human behavior: the microsystem (interactions with social groups); the mesosystem (interactions in organizational settings); and the exosystem (interactions within the larger society).

Since the 1980s, these levels have evolved and become better defined in health communication research. Several organizations, including the U.S. Centers for Disease Control and Prevention and the World Health Organization, use an ecological and multilevel approach to address a variety of health issues from violence prevention to cancer screening compliance (Colorectal Cancer Control Program, or CRCCP, in 2009). The ecological model of health behavior is commonly used to inform health-related MLIs. This model focuses on five levels of influence (i.e., intrapersonal, interpersonal, institutional, community, and policy). These levels and examples of their role in MLIs are highlighted below.

Intrapersonal level. The intrapersonal level utilizes communication strategies to target individual characteristics (e.g., knowledge, attitudes, skills, and developmental history). Health communication theories are used to inform and develop these communication strategies. For instance, the National Institute for Occupational Safety and Health targeted coal miners to modify their safety behaviors in order to help reduce their likelihood of overexposure to respirable coal dust during work shifts. The health belief model was used to identify perceived barriers to and benefits of modifying behaviors on the job, if workers felt susceptible to contracting black lung disease, if workers possessed enough self-efficacy to utilize new technology to help them track and minimize exposure to dust, and whether workers had the ability to make changes to their surrounding environment to reduce exposure to dust.

Interpersonal level. The interpersonal level takes into account formal/informal networks (e.g., family, friends, and coworkers) that individuals are surrounded by to implement communication strategies that encourage healthier behaviors. In the CRCCP, family, health care providers and community health workers were targeted as sources of interpersonal messages to make recommendations about cancer prevention screenings and provide support to remove perceived and environmental barriers to being screened.

Institutional level. The institutional level focuses on how communication that occurs within specific settings (e.g., schools, workplaces, neighborhoods) may facilitate healthier behaviors. For example, as a result of workplaces restricting smoking on-site, employees who smoke consume fewer cigarettes during work hours. In addition, providing gyms and/or walking trails on-site may encourage physical activity among employees.

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