NCCIH Research Blog

Complex and widespread public health issues such as obesity, loneliness, climate change, and health disparities require we consider a whole person orientation that looks at interactions among biological, behavioral, social, and environmental factors across individuals, families, communities, and populations. This is central to the National Center for Complementary and Integrative Health (NCCIH) Strategic Plan. 

To impact the whole person, interventions may need to move beyond intervening on knowledge, attitudes, and behaviors of individuals to intervene on upstream determinants that drive health and health inequities. For example, upstream determinants such as access to effective and affordable health care, supportive social networks, and safe, walkable neighborhoods have a significant influence on public health and well-being.

Multilevel interventions that include complementary and integrative health approaches may be a uniquely effective way to address whole person health with sustained impact. Recognizing this need, NCCIH recently updated our priority language in our clinical trial notices of funding opportunities to include multilevel intervention research “where at least one level of interventions includes a mind and body intervention.” But what are multilevel interventions exactly and how are they conducted?

What Is a Multilevel Intervention?

Multilevel interventions address two or more levels of influence in the social-ecological model (e.g., individual, interpersonal, organizational, community, or societal) to impact health (see Whole Person Health: What You Need to Know and National Institute on Minority Health and Health Disparities Research Framework). For example, a mindfulness intervention to promote better stress regulation among children in schools would be an individual-level intervention. An intervention that provides more community space to foster social connection would be a community-level intervention. A multilevel intervention may include behavioral changes in the school (individual level) and within families (interpersonal level), as well as environmental changes in the community (community level) to provide a more comprehensive approach that includes both downstream and upstream determinants to improve health. 

How Are Multilevel Interventions Conducted?

A full description of how to conduct this type of intervention is beyond the scope of this blog post, but fortunately the National Institutes of Health (NIH) has numerous helpful resources:

• Multilevel Intervention Training Institute (MLTI) Course Modules—The National Cancer Institute hosted this training institute to provide a grounding in conducting multilevel intervention research. All training materials are archived.
• The National Heart, Lung, and Blood Institute convened a workshop to provide recommendations for designing and implementing multilevel interventions that target hard-to-reach, high-risk, or vulnerable populations and communities. Discussions and recommendations are archived.
• The NIH Office of Disease Prevention provides a search tool to find Federal courses, webinars, and online tutorials in prevention research methodology, including multilevel interventions. 
• The NIH Research Methods Resources page provides tools, online courses, and other resources to help researchers design and analyze trials that randomize groups or deliver interventions to groups.

Importantly, multilevel interventions often require transdisciplinary teams and community partnerships to design and implement these complex types of interventions, as well as to share the results with people in communities. Investigators often ask us what effective engagement looks like. The following Federal resources provide guidance on identifying and meaningfully engaging with partners throughout the research process and after the study is complete:

• NCCIH Hot Topics Webinar: Engaging Diverse Communities in Complementary and Integrative Health Research highlighted successful strategies and lessons learned by engaging diverse communities in complementary and integrative health research. The agenda and video recording are archived. 
• The Helping to End Addiction Long-term^® Initiative, or NIH HEAL Initiative^®, has collated a list of helpful resources on fostering and sustaining patient and community engagement.
• The HEAL Data2Action Program Implementation Guides and Measures resource includes a useful partner engagement guide (The Partner Engagement Guide), among other relevant tools.
• The NIH Pragmatic Trials Collaboratory has a helpful resource on Building Partnerships and Teams To Ensure a Successful Trial.

In addition, the National Academy of Medicine published Assessing Meaningful Community Engagement: A Conceptual Model To Advance Health Equity Through Transformed Systems for Health. This conceptual model is the same one adopted by the NIH Community Engagement Alliance Initiative.