Cleary Paul D, Gross Cary P, Zaslavsky Alan M, Taplin Stephen H
Yale School of Public Health, 60 College St., LEPH 210, PO Box 208034, New Haven, CT 06520-8034, USA.
J Natl Cancer Inst Monogr. 2012 May;2012(44):49-55. doi: 10.1093/jncimonographs/lgs010.
Multilevel interventions, implemented at the individual, physician, clinic, health-care organization, and/or community level, increasingly are proposed and used in the belief that they will lead to more substantial and sustained changes in behaviors related to cancer prevention, detection, and treatment than would single-level interventions. It is important to understand how intervention components are related to patient outcomes and identify barriers to implementation. Designs that permit such assessments are uncommon, however. Thus, an important way of expanding our knowledge about multilevel interventions would be to assess the impact of interventions at different levels on patients as well as the independent and synergistic effects of influences from different levels. It also would be useful to assess the impact of interventions on outcomes at different levels. Multilevel interventions are much more expensive and complicated to implement and evaluate than are single-level interventions. Given how little evidence there is about the value of multilevel interventions, however, it is incumbent upon those arguing for this approach to do multilevel research that explicates the contributions that interventions at different levels make to the desired outcomes. Only then will we know whether multilevel interventions are better than more focused interventions and gain greater insights into the kinds of interventions that can be implemented effectively and efficiently to improve health and health care for individuals with cancer. This chapter reviews designs for assessing multilevel interventions and analytic ways of controlling for potentially confounding variables that can account for the complex structure of multilevel data.
越来越多的人提出并采用在个体、医生、诊所、医疗保健机构和/或社区层面实施的多层次干预措施，他们认为与单层次干预措施相比，这些措施将在与癌症预防、检测和治疗相关的行为方面带来更显著和持续的改变。了解干预措施的各个组成部分如何与患者的治疗结果相关联，并识别实施过程中的障碍非常重要。然而，允许进行此类评估的设计并不常见。因此，扩展我们对多层次干预措施知识的一个重要方法是评估不同层面的干预措施对患者的影响，以及不同层面影响因素的独立和协同效应。评估干预措施对不同层面结果的影响也会很有帮助。与单层次干预措施相比，多层次干预措施的实施和评估要昂贵得多且复杂得多。然而，鉴于关于多层次干预措施价值的证据非常少，主张采用这种方法的人有责任进行多层次研究，以阐明不同层面的干预措施对预期结果的贡献。只有这样，我们才能知道多层次干预措施是否比更有针对性的干预措施更好，并更深入地了解哪些类型的干预措施可以有效且高效地实施，以改善癌症患者的健康状况和医疗保健。本章回顾了评估多层次干预措施的设计以及控制可能导致多层次数据复杂结构的潜在混杂变量的分析方法。
