The concept of time introduces important complexities in designing and evaluating programs, measuring and analyzing individual changes, and estimating intervention effects in multilevel interventions (MLIs). For example, investigators may focus on time to address whether interventions are more effective in early stages of implementation or whether their effects attenuate over time. Assessing how time is experienced by individual patients may influence both the design of MLIs and the analysis of the effects of such interventions. For example, assessing how interventions interact with individual growth trajectories to affect outcomes of interest may allow investigators to gain a more nuanced understanding of an intervention's impact on individuals. At the environmental and organizational levels, interventions that change structures or processes often play out over extended time intervals and not always in linear fashion.In this chapter, we discuss issues of time related to 1) conceptual relevance of time in multilevel cancer interventions, 2) time as a research and program design issue in MLIs, 3) analytic methods for dealing with time in MLIs, and 4) resource considerations and trade-offs when incorporating time as a component of multilevel research.
Conceptual Relevance of Time in Multilevel Cancer InterventionsThe empirical literature is scant regarding the role of time in MLI research. The limited number of published studies have cited the challenges of insufficient time allowed for implementing the intervention (1) and for introducing changes into existing work load or routines. Some work has described different ways in which time may be treated in the context of intervention studies. Time has been conceptualized in four ways: 1) "clock and calendar time," which is structured, and addresses "when," "how often," "how long," and "in what order" activities need to occur (this conceptualization recognizes that time may be linear but its effects as experienced are frequently nonlinear); 2) "temporality," which conveys processes that unfold in time; 3) "timing," which is dependent on the organizational context in which an intervention is applied; and 4) "tempo," which is related to a patient's perception of time (eg, the rate at which a patient perceives his or her disease to have progressed) (2,3).The Symptoms Experience in Time (SET), developed for symptom management research, is another conceptual model for understanding time. It incorporates antecedents that include a precipitating event, such as cancer or a disease process. In addition to clock/calendar time and tempo, three other temporal assumptions describe time as both a concrete (ie, biological/social time) and an abstract concept (ie, sense of timelessness amid intense symptoms) (4).This conceptual work underscores the importance of understanding complex temporal dynamics from both the patient's perspective and the care delivery standpoint when planning or analyzing MLIs. Such notions of time imply a range of dynamic interactions between the intervention...