Multilevel Health Intervention Studies
Health disparities and inequities are best addressed at multiple levels including individual, neighborhood, group, community, social, and policy levels.15 Several CBPR studies have used the socioecological model to plan multilevel health inter- ventions.16 According to this model, health interventions can be aimed at the individual, the social, or interpersonal level (e.g., friends, family, coworkers), the organizational level (e.g., healthcare providers and employers), and the structural or environmental level (e.g., the built environment). Health interventions can also be aimed at the level of the community or public policy. In practice, health intervention research (e.g., community context, organizational setting, policy environment) is often multilevel and crosses socioecological levels, even when it is not conducted or reported as such.17
Dissemination and Implementation Research
Dissemination refers to the active promotion or support of a health program to encourage its widespread adoption.18 This includes the adaptation, evaluation, implementation, and maintenance of an intervention that has been shown to be effective. In contrast, diffusion is the passive process by which a health program becomes routine practice. Even when research findings are published, successful evidence-based programs only rarely diffuse passively to become routine practice. Instead, active efforts are needed to disseminate research-tested health interventions to other communities.18 Dissemination requires foresight, long-term planning, and support. The potential for dissemination should be a consideration throughout the planning, implementation, evaluation, and reporting stages of health intervention research.18 The dissemination and translation of CBPR findings to address public health concerns helps ensure that the research has pragmatic results that lead to the greatest possible benefit.
There can be barriers to the dissemination of effective health interventions, including intensive time requirements, high cost, a requirement for a high level of staff expertise, and a failure to consider future user needs when developing the intervention. Programs that are well packaged, modular, readily customized, and self-sustaining are more likely to be disseminated.18 In conducting dissemination and implementation studies, researchers should evaluate program maintenance, sustainability, and costs and select representative populations.19
The CBPR approach increases the potential of the translational sciences to develop, implement, and disseminate effective public health interventions in diverse communities.20 Relative to nonparticipatory research studies that do not involve partnerships with community residents or organizations, findings from CBPR are more likely to be disseminated to diverse audiences and to be translated into useful outcomes, such as improvements in policy.21
There are several definitions of implementation and dissemination research. Here, we are concerned with strategies to adapt evidence-based health interventions in order to effect change within specific community settings. In attempting to translate evidence from one setting to another, researchers and their community partners must consider variability in culture, resources, and community acceptance of research. For example, evidence-based interventions for increasing colorectal cancer screening that were developed for African Americans and found to be effective can be adapted for use in promoting colorectal cancer screening among other groups (e.g., Haitian Americans) and tested for effectiveness in randomized controlled trials or quasi-experimental studies. To maintain fidelity and minimize loss of impact of the intervention, evidence-based strategies and theoretical models and frameworks should be used to guide the adaptation of interventions.22,23
Several theories and frameworks have been proposed for use in dissemination and implementation research.24 Diffusion of innovations theory and the reach, efficacy, adoption, implementation, maintenance (RE-AIM) framework have been used to adapt evidence-based interventions in studies involving dissemination and implementation research.18-23 The diffusion of innovations theory addresses the process by which new ideas (e.g., innovative health interventions) are adopted by a target group or community.25 People who are “innovators” or “change agents” are respected leaders who will implement the intervention and influence public opinion. “Early adopters” are persons or organizations who will adopt an intervention before others in the community and who readily see the value or utility of the intervention.25 The RE-AIM dimensions for dissemination of an evidence-based health intervention include its reach (the percentage of the target population that comes into contact with it), effectiveness (whether the intervention achieves its targeted outcomes), adoption (the percentage of target settings and organizations that use it), implementation (how many staff within a setting or organization try it), and maintenance (whether the intervention produces lasting effects at the individual and setting level).18-26 Other considerations are whether the intervention reaches those who are most in need and whether it is adopted by organizations serving underserved or high-risk