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Scholars and practitioners frequently make recommendations to develop family planning interventions that are "multilevel." Such interventions take explicit account of the role of environments by incorporating multilevel or social-ecological frameworks into their design and implementation. However, research on how interventions have translated these concepts into practice in the field of family planning--and generally in public health--remains scarce. This article seeks to review the current definitions of multilevel interventions and their operationalization in the field of family planning. First, we highlight the divergent definitions of "multilevel interventions" and show the persistent ambiguity around this term. We argue that interventions involving activities at several levels but lacking targets (i.e., objectives) to create change on more than one level have not incorporated a social-ecological framework and should therefore not be considered as "multilevel." In a second step, we assess the extent to which family planning interventions have successfully incorporated a social-ecological framework. To this end, the 63 studies featured in Mwaikambo et al.'s systematic review on family planning interventions were reexamined. This assessment indicates that the multilevel or social-ecological perspective has seldom been translated into interventions. Specifically, the majority of interventions involved some form of activity at the community and/or organizational level, yet targeted and measured intrapersonal change as opposed to explicitly targeting/measuring environmental modification.

Multilevel interventions are inspired by socio-ecological models, and seek to create change on various levels--for example by increasing the health literacy of individuals as well as modifying the social norms within a community. Despite becoming a buzzword in public health, actual multilevel interventions remain scarce. In this commentary, we explore the operational and empirical barriers to designing and implementing multilevel interventions, and argue that the current theoretical framework based on the socio-ecological model is insufficient to guide those seeking to design multilevel interventions. We consider two theories, namely, the complementarity principle theory and the risk compensation theory--to address the gap between theory and translation into practice.

Purpose: The purpose of this paper is to study the characteristics of the participants and the success of the recruitment methods and increase in knowledge of participants in reproductive health peer education. Dutch perinatal mortality rates are relatively high compared to other European countries. Non-Western ethnic minorities show particularly adverse outcomes. They seem to have low health literacy and less access to health care. Design/methodology/approach: These groups were specifically targeted, and reproductive health education covering the full spectrum of obstetric care was developed, led by specifically trained female peer educators coming from the targeted communities. Findings: "Active" recruitment methods were the most successful methods; 1,896 women and 275 men were recruited and participated in the intervention. Sixty-five per cent of the total female participants had a first-generation immigrant background. Significant knowledge improvements were found on all five measurements of reproductive behaviour and antenatal and postnatal health care system knowledge (24 per cent average knowledge increase in already knowledgeable participant group and 46 per cent in the not knowledgeable group). Active interpersonal recruitment methods were most successful in reaching the target groups. Peer education resulted in knowledge increase in these groups. Practical implications: Invest in training of educators for peer education reproductive health. Organize recruitment by verbal advertising by community organizations and social networks of peer educators. Originality/value: To the authors' knowledge, no studies have been conducted combining investigation of the results of specific recruitment methods, the characteristics of reached participants in a multi-ethnic population and their increase in knowledge about reproductive health and care.