Or increasing awareness of and access to resources needed to prevent

Or increasing awareness of and access to resources needed to prevent infection or provide testing or care for the infected. In general, such efforts require a significant and long-term commitment of resources to achieve measurable outcomes. In some cases, because of the complex inputs in multilevel or structural interventions and the potential for numerous unanticipated or unmeasured confounders, the reasons for a lack of measurable affects of these interventions, or even for their stunning successes, might not easily be identified. Structural Intervention Design and Evaluation Challenges in the measurement and evaluation of structural intervention outcomes are increasingly the topic of scholarly debate. There is a lack of consensus about the appropriate research designs to provide valid outcome data. Particularly in question is the appropriateness of the randomized controlled trial (RCT) as an effective evaluation design for structural interventions.100,101 Although RCT remains the gold standard for testing medical instruments, new drugs, and individual-level behavioral interventions, the value of RCT when testing multilevel and community-level interventions is less clear and its limitations are increasingly evident.102,103 RCTs may not answer the questions of greatest importance, such as what systems are most malleable, what leadership factors lead organizations to success, and what factors lead to sustainability. Furthermore, issues of feasibility (e.g., randomization of sufficient “units” of study, such as cities, communities, macro networks, etc., while preventing contamination of control and intervention arms) and ethical considerations (e.g., the potential for greater benefits than just health, and for unanticipated negative consequences in randomized units) raise questions about the ultimate scientific and social benefits of using RCT designs to test structural interventions.100,104,105 Alternative evaluation designs are needed that allow intensive study of the complex iterative and interactive change processes in the local context.101,102,104 These include such alternatives as qualitative and I-CBP112 msds observational studies,105-108 multiple baseline or crossover studies,109comprehensive dynamic trials,110 and comparative case studies.111-114 These alternative research designs address weaknesses of RCT through the use of multilevel modeling and various time series approaches that structure comparisons within a small number of “case studies” (or communities) over time. They address interactions across levels through careful designation in advance and measurement of intervention GGTI298 biological activity components at each level, and through measurement of inter-level exposures using ethnographic observation. Thus, they are better suited to testing multi-level community intervention change processes and outcomes and are designed to increase external validity.115 These alternatives allow for measures of the dynamic interplay between community forces and key intervention factors. Process evaluation and analysis are essential components of non-RCT research designs because of the need to understand the relationships and interactive processes among levels of outcomes and to test hypothesized causal factors expected to affect outcomes in order to understand why the program worked, or did not, and theAIDS Behav. Author manuscript; available in PMC 2011 December 1.NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author ManuscriptLatkin et al.Pagemechanisms involved.Or increasing awareness of and access to resources needed to prevent infection or provide testing or care for the infected. In general, such efforts require a significant and long-term commitment of resources to achieve measurable outcomes. In some cases, because of the complex inputs in multilevel or structural interventions and the potential for numerous unanticipated or unmeasured confounders, the reasons for a lack of measurable affects of these interventions, or even for their stunning successes, might not easily be identified. Structural Intervention Design and Evaluation Challenges in the measurement and evaluation of structural intervention outcomes are increasingly the topic of scholarly debate. There is a lack of consensus about the appropriate research designs to provide valid outcome data. Particularly in question is the appropriateness of the randomized controlled trial (RCT) as an effective evaluation design for structural interventions.100,101 Although RCT remains the gold standard for testing medical instruments, new drugs, and individual-level behavioral interventions, the value of RCT when testing multilevel and community-level interventions is less clear and its limitations are increasingly evident.102,103 RCTs may not answer the questions of greatest importance, such as what systems are most malleable, what leadership factors lead organizations to success, and what factors lead to sustainability. Furthermore, issues of feasibility (e.g., randomization of sufficient “units” of study, such as cities, communities, macro networks, etc., while preventing contamination of control and intervention arms) and ethical considerations (e.g., the potential for greater benefits than just health, and for unanticipated negative consequences in randomized units) raise questions about the ultimate scientific and social benefits of using RCT designs to test structural interventions.100,104,105 Alternative evaluation designs are needed that allow intensive study of the complex iterative and interactive change processes in the local context.101,102,104 These include such alternatives as qualitative and observational studies,105-108 multiple baseline or crossover studies,109comprehensive dynamic trials,110 and comparative case studies.111-114 These alternative research designs address weaknesses of RCT through the use of multilevel modeling and various time series approaches that structure comparisons within a small number of “case studies” (or communities) over time. They address interactions across levels through careful designation in advance and measurement of intervention components at each level, and through measurement of inter-level exposures using ethnographic observation. Thus, they are better suited to testing multi-level community intervention change processes and outcomes and are designed to increase external validity.115 These alternatives allow for measures of the dynamic interplay between community forces and key intervention factors. Process evaluation and analysis are essential components of non-RCT research designs because of the need to understand the relationships and interactive processes among levels of outcomes and to test hypothesized causal factors expected to affect outcomes in order to understand why the program worked, or did not, and theAIDS Behav. Author manuscript; available in PMC 2011 December 1.NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author ManuscriptLatkin et al.Pagemechanisms involved.