MPH 520 Week 5 Designing a Multilevel Behavioral Intervention Example

Five Levels, One Goal: A Multilevel Diabetes Prevention Intervention From the Individual Class to City Policy in a Southern Colorado Community

[Student Name]

University of Phoenix

MPH/520: Social and Behavioral Aspects of Public Health

Week 5 Assignment

[Instructor Name]

[Date]

The county health department, its partners and the intervention plan are composites written for a model paper; research findings come from the sources cited.

After a year of analysis, the director of the composite southern Colorado health department asked the diabetes team for a plan that went beyond the prevention class. The team had learned that referrals rarely became enrollment, that food budgets ran out at month's end, that recipes ignored family traditions and that pregnancy was a missed window. This paper presents the multilevel intervention the team designed.

Why Multilevel

The team's analyses showed that diabetes risk is shaped by individual beliefs, family meals, clinic systems, neighborhood food and walking conditions and policies affecting prices and schools. An intervention at one level alone would push against forces at the others.

The Ecological Model

An ecological perspective on health promotion identifies five levels of influence: intrapersonal factors, interpersonal processes and groups, institutional or organizational factors, community factors and public policy. It holds that changes in the social environment produce changes in individuals, and that support from individuals is needed to implement environmental change (McLeroy et al., 1988).

Level One: Individual

The core individual strategy is the year-long lifestyle change program, now offered at clinics, churches and online, in English and Spanish, with weekend and lunchtime groups.

Evidence for the Individual Level

The national program has a record to guide expectations. Evaluators of the program's first four years found that the typical participant came to 14 sessions and dropped about 4% of body weight, with a little over a third hitting the 5% target; each extra session attended and each extra half hour of weekly activity came with another 0.3% of weight lost (Ely et al., 2017). Attendance is the program's engine, so every barrier removed from attendance is worth measuring.

Level Two: Interpersonal

Promotoras co-lead groups and follow up by phone. Two sessions include spouses and adult children, and adapted family recipes make changes a household project rather than one person's diet.

Level Three: Organizational

Clinics will change referral systems: clinicians explain prediabetes as a warning, schedule the first session during the visit and receive attendance updates. Prenatal clinics will follow women after gestational diabetes. The two largest employers, the steel mill and the regional hospital, will host worksite programs scheduled around shifts.

Level Four: Community

The department will partner with the food bank on diabetes-friendly food boxes timed for month's end, expand a program doubling food assistance dollars for fruits and vegetables at the farmers market and work with neighborhood groups on lit, safe walking routes and walking clubs after church.

Level Five: Policy

At the policy level, the department will support water stations and limits on sugary drinks in schools, healthy options in county vending machines and a study of a local beverage tax.

Evidence for Policy

Policies can change behavior at scale. After Philadelphia implemented a tax on sweetened beverages, volume sales of taxed drinks in the city fell 51.0%, although increased sales in bordering areas offset about a quarter of the decline, for a net reduction of roughly 38% (Roberto et al., 2019). The border effect suggests that a regional approach would work better than a single city acting alone.

How the Levels Reinforce One Another

The levels work together. A participant in the class learns to replace sugary drinks with water; her family supports the change; her employer's cafeteria offers water and healthier options; her neighborhood has a safe walking route; and her children's school no longer sells soda. Each level makes the others easier.

Choosing Strategies With Evidence and Fit

The team rated candidate strategies on two questions: is there evidence it works, and does it fit this community? Some strategies with strong evidence, such as intensive medical weight management, were too costly to offer widely. Others that fit the community well, such as church walking clubs, had weaker evidence but low cost and strong support. The final plan balances both.

Resources and Partners

The plan relies on partners at every level: clinics for referral, the food bank for food boxes, employers for worksite programs, churches for classes and walking clubs, the school district for water policies and the city for walking routes. The department coordinates, funds promotoras and a program manager and seeks Medicaid and employer payment for the prevention program.

Anticipating Resistance

Some stakeholders will resist parts of the plan. Beverage retailers and some residents will oppose a tax. Some employers may doubt the value of worksite programs. The department will present evidence, start where support is strongest and treat the tax as a study rather than a proposal, giving the community time to weigh it.

Sustaining the Program

Grant funding will not last forever. The department is pursuing reimbursement for the prevention program through Medicaid and the regional hospital's employee health plan, and building the promotora role into its permanent budget so the program outlasts the initial grant.

Community Involvement

A community advisory group of residents, promotoras, clergy, employers and school representatives chose the community and policy strategies and will review progress quarterly.

Addressing Equity

The plan puts resources first where diabetes is most common and incomes lowest, where food boxes, walking routes and promotoras are placed first.

Learning as the Plan Unfolds

The team will review results every six months and adjust. If worksite programs attract few participants, resources will shift to churches and clinics. If the food boxes reduce end-of-month hypoglycemia calls, they will be expanded. A multilevel plan is a hypothesis about how change will happen, and it should be tested and revised.

Implementation Timeline

Year one launches the expanded classes, family sessions, clinic referral changes and food box partnership. Year two adds worksite programs, walking routes and school water policies. Year three brings the beverage tax study to the city council.

Measures by Level

Individual: enrollment, sessions attended and weight change. Interpersonal: family session participation. Organizational: referral-to-enrollment rates and employer participation. Community: food boxes distributed and walking club participants. Policy: schools adopting water policies and council action on the tax study.

Why Not Start With Policy Alone

Some advisory group members asked why the department did not focus entirely on policy, given the evidence of its reach. The team's answer was that policy change takes years and depends on public support, which programs help build by showing residents and leaders what healthier environments look like. Programs and policies are meant to advance together.

Overall Outcomes

Long-term outcomes include diabetes incidence among participants and county diabetes prevalence estimates over time, tracked for at least five years.

Conclusion

Diabetes in the community is shaped at five levels, and the intervention acts at all five. An ecological model organized the design, evidence from the national prevention program set realistic expectations for the individual level and evidence from a city beverage tax informed a cautious policy step. Strategies that reinforce one another across levels give the department its best chance to prevent diabetes, not only to teach about it.

References

Ely, E. K., Gruss, S. M., Luman, E. T., Gregg, E. W., Ali, M. K., Nhim, K., Rolka, D. B., & Albright, A. L. (2017). A national effort to prevent type 2 diabetes: Participant-level evaluation of CDC's National Diabetes Prevention Program. Diabetes Care, 40(10), 1331-1341. https://doi.org/10.2337/dc16-2099

McLeroy, K. R., Bibeau, D., Steckler, A., & Glanz, K. (1988). An ecological perspective on health promotion programs. Health Education Quarterly, 15(4), 351-377. https://doi.org/10.1177/109019818801500401

Roberto, C. A., Lawman, H. G., LeVasseur, M. T., Mitra, N., Peterhans, A., Herring, B., & Bleich, S. N. (2019). Association of a beverage tax on sugar-sweetened and artificially sweetened beverages with changes in beverage prices and sales at chain retailers in a large urban setting. JAMA, 321(18), 1799-1810. https://doi.org/10.1001/jama.2019.4249