Two months into the new year, many are finding how hard it is to make lasting changes, such as quitting smoking, exercising more or eating smarter. These and other behaviors have been identified as important risk factors for chronic disease. Research shows that factors beyond our own efforts to change make a difference in our success or failure. Reducing health risks and promoting health by also changing external influences are called multilevel interventions - using innovative approaches to help people make long-term changes for the better.

• More than 80 percent of patients fail to follow recommendations for behavioral changes such as quitting smoking or following a restrictive diet. [1]
• Researchers estimate that only about 25 percent to 33 percent of heart patients who would benefit from cardiac rehabilitation (exercise, education, counseling and behavioral interventions) adhere to health professionals' rehabilitation recommendations. [2]
• Success in sticking with an exercise program depends on the type of exercise and other factors, but studies indicate that about 50 percent of adults who start an exercise program on their own will stop exercising within the first six months. [3,4]


• More than 80 percent of smokers say they would like to stop smoking and at least 1 million smokers quit every year. [5] Smokers may go through several rounds of quitting smoking, starting again and quitting again before they are successful in stopping smoking. Most smoking relapses happen with the first three months after quitting. [4]
• Physical activity helps women maintain weight loss: 90 percent of women who were successful at losing weight and keeping it off also exercised regularly. In contrast, only 34 percent of women who lost weight and gained it back were regular exercisers. [6]
• Almost 40 percent of deaths in the United States are attributable to smoking, physical inactivity, poor diet or alcohol abuse. [7]
• Chronic disease costs the United States hundreds of billions of dollars every year: Approximately $300 billion was spent on all cardiovascular diseases in 2001. Direct and indirect costs associated with diabetes annually are estimated at $100 billion a year. Annual costs of obesity and overweight are estimated to be $117 billion. [8,9]
• More than 45 million adults are obese and the percentage of children and teens who are overweight has increased dramatically in the past 20 years. Approximately 8 million young people - 10 percent to 15 percent of children ages 6-17 - are overweight. [9]
• Physical inactivity is associated with visiting a physician more often, being hospitalized more often and needing more medication. [10] More than 60 percent of American adults do not get enough physical activity to reap any health benefits and at least 25 percent are not active at all in their non-work time. [9]

Defining the Challenge: How Multilevel Intervention Approaches Work with Russ Glasgow, Ph.D.

Russ Glasgow, Ph.D., is senior scientist in the Clinical Research Unit at Kaiser Permanente in Colorado and is trained in clinical psychology. The current focus of his work is public health and health behavior change. He is a member of the Behavior Change Consortium of the National Institutes of Health and of the RE-AIM work group of the BCC to evaluate and enhance the reach and dissemination of health promotion interventions. The RE-AIM Workgroup, supported by a grant from the Robert Wood Johnson Foundation and online at http://www.re-aim.org, works to improve implementation and evaluation of health promotion interventions and offers information, tools and resources for health behavior researchers.

Q. What are multilevel interventions?

A. Multilevel interventions are comprehensive approaches to those things that make it harder or easier to change health behavior and are found at varying degrees of proximity to the individual. So these can be things in your immediate environment, like your family, your relationship with your medical care provider or in the communities where you live, work and play.

Q. Are there even greater barriers and opportunities in the larger world?

A. Sure. As you move slightly farther away from things that are in the immediate orbit of the individual, there are other influences on health behavior. These include the media, which produce lots of messages about health and health behavior. And there are barriers and resources for change at the level of local, state and national policy, including taxation. A good example of this is the impact that cigarette taxes have on smoking - increases in cigarette taxes decrease smoking.

Q. What would multilevel interventions look like for a specific behavior or disease?

A. Let's take diabetes prevention and treatment as an example. Diet and exercise are very important in preventing diabetes. They are also important in managing the disease if it develops. So interventions in the person's immediate environment might be to work with the patient to think about healthy meals and how to structure them with his or her family. Another intervention could be to look at the individual's patterns of eating out and what's available in terms of restaurants in the local community. Collaborating with primary care physicians to recommend safe and effective levels of exercise is another example of components of a multilevel intervention.

Q. So it's a series of independent steps?

A. No. None of these behaviors - eating at home, seeing the doctor, exercising, eating out - occur in isolation. From a multilevel intervention perspective, it's important to think about the larger environments beyond the individual and his or her family that make it easier or harder to achieve behavior change goals and how these factors all work together.

Q. What questions might help develop the appropriate multilevel interventions in this case?

A. What are the barriers that might keep this person from exercising and maintaining a healthy diet? What are the community resources that are available? Are there safe places in the community to exercise? What kind of food is readily available and affordable? Interventions at this level might include working with the community to create safe, well-lighted bicycle and walking paths, or working with local restaurants and grocery stores to label foods that are healthier choices.

Q. Why are multilevel interventions being used more frequently?

A. Researchers and program developers are recognizing that influences on health behavior are very complex. Behavior doesn't exist in a vacuum. Our social, physical, cultural and economic environments influence the way we act and the decisions we make.

It's also becoming clearer that changing health behavior is a very complex process. We're beginning to understand how important these larger environments are in keeping behavior change at the individual level. Recognizing the inherent complexity of behavior and change is what sets multilevel interventions apart from individual approaches. In some ways, this makes multilevel interventions more realistic, more real world. Using a multilevel intervention approach also makes it possible to tailor interventions to the specific needs of the people being served.

Q.How successful have multilevel interventions been in helping people change health behaviors?

A. There is growing evidence that multilevel interventions are successful in tackling hard-to-change behaviors. One example of this success has been smoking-cessation programs in some health care settings. These programs, shown to be more cost-effective than other types of smoking-cessation interventions and most other medical interventions, offer a kind of "stepped care" that targets specific services to people with different needs.

Q. What steps are involved?

A. The first is to offer intervention to an entire group, such as all patients served by a health maintenance organization. All patients would receive minimal written materials about stopping smoking. The next step would be to offer a more intensive intervention, such as a stop-smoking program that included counseling with a pharmacist, to a subgroup of people. This subgroup might include people who are more motivated to quit or less successful at quitting than others in the original large group. A final step would be to offer a more intensive intervention, such as a smoking-cessation group and prescription medications, to a smaller subgroup that was at very high risk or having little success in quitting.

Q. Are there any drawbacks to multilevel interventions?

A. Using this approach to help people achieve their health behavior change goals is challenging. It's not always immediately apparent why the interventions work or don't. These programs also can seem like they are more costly when they are first proposed because of their complexity. It's often the case, though, with defined populations that multilevel interventions are less costly, as is true with the "stepped" smoking-cessation programs I described. Something that isn't a drawback, but is often a challenge, is the number of partners involved in designing, implementing and evaluating a multilevel intervention program.

Q. What types of partners?

A. Multilevel interventions often have an impact on everyone in a community. It's important to involve the people who are the target audience for the intervention. It's also important to involve the people who will be delivering the intervention - the professionals or helpers who will be actually delivering the services. Involving decision-makers is also really important.

By involving all of these people from the outset, you can become aware of and prevent big problems. Partnerships make it much more likely that the program will be realistic and effective - that it will reach and appeal to the people it was intended to reach - and that it will stay in place.

Multilevel interventions are also multidisciplinary. Partnerships among people who understand the psychological, social, community, economic and political aspects of the intervention are critical to the success of the interventions.

Q. What has research on multilevel interventions told us?

A. One important lesson from the past decade is the importance of reaching minority participants, women and the underserved in representative proportions in our research.

It's a mistake to assume that because an intervention worked for middle-class white males, it will work for everyone. The issue we're facing now and need to work on over the next decade is that the same lesson applies at "higher levels" of the intervention.

These levels include the setting in which the intervention is offered (home, a physician's office or a community organization), and the people and technology that offer the intervention and provide services.

It does little good to develop the "perfect intervention" if no setting will adopt it or only a handful of world-class counselors can deliver it. The number of settings in which research is conducted and how representative they are of the settings in which the services would actually be delivered are just as important as the number of individuals who participate in the study and how representative they are of others who might participate.

The same is true of the number and representativeness of the people who deliver the services. If we want to develop interventions that are going to be effective in the real world, these are the kinds of things we need to be thinking about.

Practical Applications: Multidimensional Foster Care Programs Cover the Bases with Patricia Chamberlain, Ph.D.

Patricia Chamberlain, Ph.D. is senior researcher and executive director of community programs at the Oregon Social Learning Center, a nonprofit, independent research center dedicated to increasing scientific understanding of processes related to healthy development and family functioning. Dr. Chamberlain has been instrumental in the design, implementation and evaluation of multidimensional foster care programs that serve children and youth at high risk in Eugene, Ore. These programs are now being replicated and studied in other parts of the country.

Q/ What are multidimensional treatment foster care programs?

A/ These programs serve children and youth in the juvenile justice, mental health and child welfare systems. The models differ slightly for each of these three systems. But in general, the programs provide comprehensive services to children, youth and families. Our research indicates that these comprehensive services are more effective in addressing the needs of kids and families than traditional services.

Q/ Can you give an example?

A/ Let's take the juvenile justice system. Multidimensional treatment foster care is an alternative to group care, residential care or incarceration for teens with conduct problems. These kids would typically be sent to locked or segregated placements.

We provide an intensive multilevel intervention, which includes services for the teens, their families of origin and their foster families, while keeping teens in their home communities. We recruit foster families and provide them with training and ongoing support and supervision. One teen is placed in each foster home.

Q/ Which teens are served by this program?

A/ Most of the teens in this particular program have long histories of conduct problems. When they come into the program, boys on average have had 14 criminal offenses. Girls on average have had 11 criminal offenses. They are usually not up to developmental level in lots of ways. They've also had problems with their previous associations with delinquent peers, especially when they are unsupervised.

The program is designed not only to stop the conduct problems, but teach behaviors at the appropriate level of development. This includes helping kids learn how to interact with their peers in positive ways, to participate in community activities and to take advantage of adult mentors.

Q/ How long do teens typically stay in the program?

A/ The average length of stay for boys is about seven months. For girls, the average stay is about nine months.

Q/ What other types are services are involved?

A/ We provide a whole range of services, including therapy for the family of origin, individual therapy for the teen and psychiatric consultations including medications and medication management.

We also provide a "skills trainer" for the teens, who is with them when they are out in the community - at team practices, with friends, at events - to provide supervision and support.

The kids we serve have a hard time taking part in normal activities and often have been kicked off teams or excluded from other activities. The skills trainers work with the teens in the program individually and out in the community to help them manage their behavior and take advantage of activities and opportunities that other teens participate in.

We also provide intensive services to the foster families. The foster families are incredibly involved and dedicated. Some of our foster families have participated in the program for 12 years.

Each treatment foster home runs a daily behavior management program. This program is individualized to the teen and the foster home. The program focuses on what the teen is doing well - points are earned for good behavior and points are lost for bad conduct.

A program supervisor is available 24 hours a day and is in daily contact with the family to provide support and intense supervision. Part of the supervision includes tracking the points the teen has earned and lost and going over a behavior management checklist with the parents.

The foster parents also participate in a weekly meeting with other foster parents of kids of the same age and gender as their foster child. These meetings provide an opportunity to talk about the problems families have dealt with in the past week and to revise and update each teen's treatment plan.

Q/ What about school attendance and performance? Are these factors addressed by the program as well?

A/ Yes, the program monitors teens' school performance. Homework completion, attendance and behavior in class are all tracked.

A central feature of the program is that it provides a lot of structure, which is what these kids need to be able to perform well. Although they might fight the structure at the beginning, most adapt well and really thrive. So another big feature of the program is to help parents provide the same kind of structure when the kids return to their homes of origin.

Q/ What kind of intervention or work does that involve?

A/ We help parents provide better supervision, follow through with consequences (for misbehavior) without anger, not let the teen hang out with delinquent friends and provide encouragement and support when the teen is doing well.

We start with just one of these, which is usually helping to provide better supervision. Part of the intervention frequently is to convince parents that it is possible to supervise teens. If they've been hanging with kids who get into trouble, teens need more supervision.

One challenge is that parents are very busy and there are many competing demands for their time. We work this out family by family, helping the families build more structure into their lives. We also provide support to help them maintain this structure.

Q/ What results have you seen?

A/ Our research indicates that teens who participate in the multidimensional treatment foster care program have fewer arrests, less self-reported criminal activity and fewer days locked up.

Boys in the foster care program were also more likely to complete the program than boys in group care. Boys in the program were also institutionalized significantly less frequently, reported fewer psychiatric symptoms, and had better school adjustment and a number of other positive outcomes.

My colleague Mark Eddy is conducting a long-term follow up of this particular program. We are particularly interested in the period between ages 18-22. Kids do a lot changing during this period and some kids appear to go in and out of an antisocial process. We are interested in learning more about what predicts this - what family, work, educational, individual and interpersonal factors influence outcomes during this time?

We've also been funded by the National Institute on Drug Abuse for a study that will focus on health outcomes such as substance abuse and sexual risk behaviors.

Q/ What led you to multilevel, multidimensional foster care interventions?

A/ We had really hit the wall just doing family therapy - even if it improved relationships within the family, the teens may still have had problems with peers, school and in other domains of their lives.

There was also a fair amount of research that indicated that kids with externalizing problems - acting-out kinds of problems - didn't do well in generalizing new patterns of behavior to other settings.

So things they may have learned in family therapy weren't really being carried out in other aspects of their lives. You have to go into different settings to make the intervention. You get more traction if you can intervene in multiple settings. And really, the comprehensive approach is much easier and much more effective over the long run.

Q/ What are other lessons learned?

A/ There are a couple. The first is that once-a-week therapy in an office doesn't work with kids with conduct disorders. You can't talk a kid out of being bad. It's about action, not talk - and about helping them learn what they need to learn.

The second is that even though programs like multidimensional treatment foster care may seem very intensive, the costs can be much lower than what they seem to be for programs that appear simpler, like residential care.

In residential care, funds are spent on buildings and shift staff. In multidimensional treatment foster care programs, money is spent on people - on program supervisors and skills trainers and others.

If the interventions are successful, there are significant cost savings in terms of services and facilities not used.

Part of the challenge in promoting health and well being is finding innovative ways to reach Americans at high risk for chronic health problems who may not be reached by typical programs.

For example, traditional health promotion programs often fail to reach African-Americans, despite their increased risk for many diseases. [11] In response, groups such as the Congress of National Black Churches have done projects to prevent diseases such as diabetes and to address public health concerns such as substance abuse, violence, AIDS, infant mortality and immunization.

Health projects of the CNBC, a coalition of eight historically black denominations, are supported through partnerships with federal agencies such as the Centers for Disease Control and Prevention and the Bureau of Primary Health Care of the Health Resources and Services Administration.

Researchers also are studying the effectiveness of multilevel interventions implemented through partnerships with black churches. Several of the intervention programs implemented through partnerships between researchers and black churches focus on improving the diets and increasing levels of physical activity of participants to help prevent cancer, cardiovascular disease and other diseases.

The daily intake of fruits and vegetables by most Americans is less than the recommended five a day, which is true of African-Americans as well. In addition, African-Americans are less likely than other Americans to be physically active. [12,13]

Studies show that there are many different ways to help people improve their diets. In one study, adding individual telephone counseling to health fairs, videos, cookbooks and printed educational materials was found to be the most effective way to help individuals eat more fruits and vegetables a day. [13]

Other research indicates that people ate more fruits and vegetables if they were attending churches where interventions were used, such as serving more fruits and vegetables at church functions, personalizing church bulletins and sermonizing on healthy eating. [14]

Projects under way to test the effectiveness of interventions to promote physical activity include the Healthy Body/Healthy Spirit Project in Atlanta, Ga. [12] This study is testing the effects of a culturally sensitive self-help physical activity and nutrition intervention and telephone counseling on exercise and nutrition behaviors.

The study is one of 15 research projects of the Behavior Change Consortium of the National Institutes of Health, being conducted with funding from the NIH and supplemental support from the American Heart Association and the Robert Wood Johnson Foundation.

The leading cause of death in all racial and ethnic groups in the United States is heart disease. [8]

Long-term changes in multiple behaviors, such as exercising, not smoking, eating well and taking appropriate medications all play a role in preventing heart disease and in significantly improving the health of cardiac patients. But despite efforts over many years to reduce risks for heart disease and improve patients' adherence to medical recommendations, the evidence indicates that most people find it difficult to maintain these changes over time. [15]

The American Heart Association's Multilevel Compliance Challenge recognizes that patients, health care providers and health care organizations all must be involved to improve the chances that individuals will be able to stick with treatment regimens and make long-lasting changes in their behaviors. [16]

The Challenge identifies actions that can be taken by patients, health care providers and health care organizations simultaneously to improve health and reduce the risks of heart disease.

Actions and strategies for patients include learning to negotiate behavior change goals with their health care providers and monitoring progress toward those goals. Recommendations for providers include developing skills in communication and counseling, providing verbal and written instructions for patients and including patients in decisions about prevention and treatment. Health care organizations are called on to develop health care environments that support prevention and treatment interventions through a variety of methods. These include training providers in behavior change strategies, providing group and individual counseling for patients and families and improving administrative systems for tracking and reporting patient care.

Examples of multilevel intervention programs and other resources:

Health Works for HEELS at the University of North Carolina at Chapel Hill is a work site program using multiple strategies to reduce health risks and improve health. http://www.ais.unc.edu/hr/heels/main_hfh.htm.

The Columbia Center for Youth Violence Prevention is a joint project of the Columbia University Joseph L. Mailman School of Public Health, the New York State Psychiatric Institute, the Columbia Institute for Child and Family Policy, the New York City Department of Health and community-based agencies. Goals of this project include studying the causes of youth violence and developing a multilevel public health intervention plan to reduce youth violence in the New York metro area. http://cpmcnet.columbia.edu/dept/sph/ccyvp/.

The Adolescent Transitions Program is a school-based program that focuses on parents and improving family management skills, including problem solving and communication, to improve adjustment and well being. http://cfc.uoregon.edu/atp.htm.

The Behavior Change Consortium is coordinated by the Office of Behavioral and Social Science Research at the National Institutes of Health. The BCC is part of an initiative to stimulate research on innovative ways to help people engage in healthy behaviors. The BCC encourages using multilevel interventions to promote and sustain health behavior change. http://www1.od.nih.gov/behaviorchange/overview.htm.

Other information about multilevel interventions include publications by the Institute of Medicine:

New Horizons in Health: An Integrative Approach. Executive summary at http://obssr.od.nih.gov/Publications/NRC_Horizons.htm#Interventions. The full report can be viewed and ordered at http://www.nap.edu/books/0309072964/html.

Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences. This book can be viewed and ordered at http://search.nap.edu/books/0309070309/html.

1. National Heart, Lung, and Blood Institute (1998). Behavioral Research in Cardiovascular, Lung, and Blood Health and Disease, Department of Health and Human Services. Cited in Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences. Committee on Health and Behavior, Research, Practice, and Policy, Board on Neuroscience and Behavioral Health, Institute of Medicine. 2001. Washington, DC: National Academy of Sciences.

2. Wenger N.K., Froelicher E.S., Smith L.K., et al. Cardiac Rehabilitation. Clinical Practice Guideline No. 17. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research and the National Heart, Lung, and Blood Institute. AHCPR Publication No. 96-0672. October 1995.

3. Sullivan P. Exercise Adherence. The Educational Resources Information Center: Digests and Publications. Digest Number: 89-3. http://www.ericsp.org/pages/digests/exercise_adherence_89-3.html.

4. Wing, R.R. Cross-cutting themes in maintenance of behavior change. Health Psychology. 2000; 19(1) Supplement 1:84-88.

5. American Heart Association. Smoking Cessation: AHA Scientific Position. http://www.americanheart.org/presenter.jhtml?identifier=4731.

6. Kayman S., Bruvold W., Stern J.S. Maintenance and relapse after weight loss in women: behavioral aspects. American Journal of Clinical Nutrition. 1990; 52(5):800-807.

7. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Chronic Disease Prevention. Tracking Major Health Risks Among Americans: The Behavioral Risk Factor Surveillance System: At a Glance 2002. http://www.cdc.gov/nccdphp/aag/aag_brfss.htm.

8. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Chronic Disease Prevention. Chronic Disease Overview. http://www.cdc.gov/nccdphp/overview.htm.

9. Centers for Disease Control and Prevention. National Center for Chronic Disease Prevention and Health Promotion. Chronic Disease Prevention. Physical Activity and Good Nutrition: Essential Elements to Prevent Chronic Diseases and Obesity: At a Glance 2002. http://www.cdc.gov/nccdphp/aag/aag_dnpa.htm.

10. Centers for Disease Control and Prevention. National Center for Disease Prevention and Health Promotion. Chronic Disease Prevention. Improving Nutrition and Increasing Physical Activity. http://www.cdc.gov/nccdphp/bb_nutrition/index.htm.

11. Demark-Wahnefried W., McClelland J.W., Jackson B., et al. Partnering with African American churches to achieve better health: lessons learned during the black churches united for better health 5 a day project. Journal of Cancer Education. 2000;15:164-167.

12. Resnicow K., Jackson A., Braithwaite R. et al. Healthy Body/Healthy Spirit: a church-based nutrition and physical activity intervention. Health Education Research. 2002;17:562-73.

13. Resnicow K., Jackson A., Wang T. et al. A motivational interviewing intervention to increase fruit and vegetable intake through black churches: results of the eat for life trial. American Journal of Public Health. 2001;19:1686-1693.

14. Campbell M.K., Motsinger B.M., Ingram A. et al. The North Carolina Black Churches United for Better Health Project: intervention and process evaluation. Health Education and Behavior. 2000;27:241-253.

15. Sher T.G., Bellg A.J., Braun L. et al. Partners for Life: a theoretical approach to developing an intervention for cardiac risk. Health Education Research. 2002;17:597-605.

16. Miller N.H., Hill M., Kottke T. et al. The multilevel compliance challenge: recommendations for a call to action. Circulation. 1997;95:1085-1090. American Heart Association. The Multilevel Compliance Challenge. http://www.americanheart.org/presenter.jhtml?identifier=436.

17. Oxford Journals; http://www3.oup.co.uk/jnls/list/healed/special/1/default.html; http://www1.od.nih.gov/behaviorchange/supplement/supplement.htm.

The Center for the Advancement of Health is an independent nonprofit organization that promotes greater recognition of how psychological, social, behavioral, economic and environmental factors influence health and illness. The Center advocates the highest quality research and communicates it to the medical community and the public. The fundamental aim of the Center is to translate into policy and practice the growing body of evidence that can lead to the improvement and maintenance of the health of individuals and the public. The Center was founded by the John D. and Catherine T. MacArthur Foundation and the Nathan Cummings Foundation, which continue to provide core funding. Funding for this series was provided by the Robert Wood Johnson Foundation.

For Information Contact:
Kristina Campbell
Editor, Health Behavior News Service
Center for the Advancement of Health
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