ISSUES & CHALLENGES Adaptation, translation, and global application DiClemente, Crosby, & Kegler, 2009

Priorities for Advancing Theory 1. Theory must be tested in practice-based settings 2. Improve cross-cultural transfer regarding theories 3. Theory development should be more inclusive of changes to the physical environment DiClemente, Crosby, & Kegler, 2009

Testing Theory in Practice-based Settings Theories are used most often in intervention research Emphasis on efficacy trials and internal validity Interventions labeled “evidence-based” may lack applicability in real- world settings Increased emphasis on external validity would provide information on the utility of theory and intervention effectiveness in diverse settings. Collaboration is important Testing theory via program evaluations (DiClemente et al., 2009)

Improving the cultural transfer of HP theory Insufficient research on the cultural transfer of HP theories Why is this an issue? (DiClemente et al., 2009)

Improving the cultural transfer of HP theory Issues with:  Applicability  Relevance  Appropriateness (DiClemente et al., 2009)

Improving the cultural transfer of HP theory Potential Solutions Develop a continuum of research to understand cultural transfer Enhance the exchange between theory developers and users Test theory (i.e., via program evaluation) (DiClemente et al., 2009)

Cultural Transfer of HP Theory: Pragmatic Strategies 1. Assessment 1. Formative research with the target population 1. Decision 1. Decide if theory has empirical support within a particular cultural context 1. Engage experts 1. Ask cultural experts about cultural applicability of the theory, its use, and the uptake of interventions based on it (DiClemente et al., 2009)

Develop Ecological Theories & Focus on Environmental Change Theory development has neglected guidance on how to achieve change The challenge:  Develop theory-based approaches to leverage changes in physical environments (DiClemente et al., 2009)

Develop Ecological Theories & Focus on Environmental Change Theory development has neglected guidance on how to change policy and law The challenge:  Develop and refine theory for efficient use E.g., include a repertoire of methods to access key political figures “…a good ecological model should provide practitioners with practical methodologies for leveraging community and political resources necessary to marshal economic support” (p. 566) (DiClemente et al., 2009)

Final Notes & Considerations Ecological theories… must not contribute to greater health disparities must be feasible should have great flexibility Another paradigm? The regulation of corporate practices, i.e. their promotion of unhealthy practices (DiClemente et al., 2009)

Strategies for combining interventions at multiple levels (Weiner et al., 2012) Social-ecological models provide a powerful justification for multi-level interventions Model implies the multiple factors that influence health are interdependent—that is, they mutually influence each other: causal influence does not flow in only one direction determinants at one level of influence can modify the effects of determinants at another level changes at one level of influence can bring about changes at another level of influence

Little guidance on developing effective multi-level interventions The key to designing effective multilevel interventions is to select and combine interventions that work together in complementary or synergistic ways But how? Find key levers or “high-leverage” factors Change the environment before trying to change people Danger of interventions that produce scattered, redundant, or contradictory effects

Focus on mediation and moderation Mediation Process or pathway through which a cause is linked to an effect Moderation Individual differences or contextual conditions that alter the strength or direction of a relationship between a cause and an effect Mediated moderation The moderating effect of some difference/condition results from differences in the mediating process or pathway The causal pathway varied for different groups/conditions Moderated mediation The mediating process or pathway is intensified or attenuated by an individual differences or contextual condition The magnitude of the mediated effect varies for different groups or conditions

1. Accumulation strategy Intervention strategies at different ecological levels all produce a cumulative impact on the mediator

2. Amplification strategy The effect of one or more interventions is conditional on another intervention. Like moderated mediation, one intervention amplifies the magnitude of the effect of the other intervention(s) on the mediating process or pathway.

3. Facilitation strategy A conditional intervention clears the mediating pathway for the other intervention(s) to produce the desired outcome. As another form of moderated mediation, one intervention removes the barriers or facilitates the effect of the other interventions.

4 Cascade strategy An intervention at one level affects the desired outcome in and through one or more interventions at other levels of influence. The interventions demonstrate sequential interdependence, meaning that the outputs of an intervention at one level become the inputs of an intervention at another level.

5. Convergence strategy Interventions at different levels mutually reinforce each other by altering patterns of interaction among two or more target audiences. The interventions exhibit reciprocal interdependence, meaning the outputs of some interventions become the inputs of other interventions and vice versa.

Discussion Helps In the selection of intervention components at different level Understand the causal processes and makes them explicit Complements other intervention planning models For example, could be used to think through the design of interventions that target the predisposing, enabling, and reinforcing factors (of the PRECEDE-PROCEED model) at different levels of influence Important to recognize that interventions at multiple levels interact not only with each other, but also with other contextual factors in the settings into which they are introduced (eg, sociopolitical processes) Multilevel interventions occur in social systems characterized by complexity, nonlinearity, and sensitivity to initial conditions