In Search of Synergy: Multilevel Implementation Interventions Bryan J. Weiner, Ph.D.
You think because you understand 'one' you must also understand 'two', because one and one make two. But you must also understand 'and'. ~ Rumi
GOT SYNERGY? • Implementation facilitators and barriers operate at multiple levels of influence • Yet, multi-level implementation interventions often don’t work better than single-level ones Why? • Selected implementation interventions do not target key determinants of the problem • Interdependence of key determinants of the problem are poorly understood
THE CAUSAL LOGIC OF MULTILEVEL INTERVENTION We explored how We concentrated on two forms interventions at different of causal interdependence: levels could mediation and moderation be combined to produce complementary or synergistic …and identified 5 potentially effects useful strategies for combining interventions at different …using a causal modeling levels framework to develop potential combinations
MEDIATION Mediator: A variable that explains (or accounts for) the relationship between the dependent variable and the independent variable. Full Mediation IV M DV 5
MEDIATION Mediator: A variable that explains (or accounts for) the relationship between the dependent variable and the independent variable Partial Mediation M IV DV
MEDIATION Mediator: a variable that explains (or accounts for) the relationship between the dependent variable and the independent variable Parallel Mediation M IV DV M
MEDIATION Mediator: A variable that explains (or accounts for) the relationship between the dependent variable and the independent variable. Serial Mediation IV M M DV 8
MODERATION Moderator: A variable that changes the strength of an effect or relationship between two variables. W IV DV
MODERATION Moderator: A variable that changes the strength of an effect or relationship between two variables. W IV DV W Multiple Moderation
MODERATION Moderator: A variable that changes the strength of an effect or relationship between two variables. Moderated W W moderation IV DV
COMBINATIONS Moderated mediation: Mediating process or pathway is intensified or attenuated by individual difference or contextual condition. IV M DV W W
SOCIAL ECOLOGICAL MODEL Levels as Settings* * Or social units
SOCIAL ECOLOGICAL MODEL Levels as Determinants
Example: Possible Barriers to or Determinants of Colorectal Cancer Screening Level of Influence Possible Barrier/Determinant Intervention Strategy Intrapersonal • Patient/provider knowledge, attitudes, beliefs • Education, training, navigation • Patient structural barriers (e.g., time, money) • Decision support • Inadequate cues to action • Reminders Interpersonal • Poor physician-patient communication • Communication • Inadequate social/spousal support • Shared decision making • Professional (social) norms about screening • Social support • Opinion leaders Organizational • Poor care coordination, inefficient processes • Quality improvement • Inadequate staffing, inadequate data systems • Service/staffing changes • Role revisions, registries Community • Low community awareness/demand • Social marketing campaign • Inadequate supply of diagnostic colonoscopy • Assisted transportation services services Macro Policy • Limited or lack of insurance coverage • Insurance coverage changes • Inadequate incentives to coordinate care • Bundled payment policies
1. ACCUMULATION STRATEGY *For expositional purposes, the diagram depicts interventions rather than determinants as causes. Public reporting* To keep the concept simple, a single mediating pathway (organizational) is presented. Physician’s Op Opinion Leader Colorectal Cancer (I (Interpersonal) Screening motivation Outreach visit Legend (Intrapersonal)) Box: intervention and level of influence (in parentheses) Diamond: mediator Oval: outcome
2. AMPLIFICATION STRATEGY Public reporting* (Organizational) Physician’s Colorectal Cancer Screening motivation Opinion leader (Interpersonal) Audit and feedback (Intrapersonal)
3. FACILITATION STRATEGY Public reporting* (Organizational) Physician’s Colorectal Cancer Screening motivation Opinion leader (Interpersonal) Clinical reminder (Intrapersonal)
4. CASCADE STRATEGY Quality Advocacy at Manager improvement state level motivation (Organizational) (Macro Policy) Office Outreach visit Physician systems (Intrapersonal) motivation Colorectal Cancer Screening
5. CONVERGENCE STRATEGY Public reporting* (Organizational) Physician motivation Opinion leader Provider- (Interpersonal) patient interaction Patient Patient education motivation (Intrapersonal) Colorectal Cancer Screening
AMPLIFICATION STRATEGY Clinician’s Incentives Participation in (Intrapersonal) Training motivation Social Opinion leader norms (Interpersonal)
WHAT’S NEEDED > Multilevel theories that explain how determinants at multiple levels interact to produce health and other outcomes > Cross-level research that examines the inter-dependence of variables (determinants) at multiple levels of influence > Knowledge of the causal mechanisms through which commonly employed implementation interventions produce their effects
Recommend
More recommend
