Locating and testing the healthy context paradox: examples from the INCLUSIVE trial

Area of Science:

• Public Health
• Psychology
• Education

Background:

• The healthy context paradox occurs when interventions reduce victimization but widen mental wellbeing gaps among remaining victims.
• This phenomenon was initially observed in school bullying interventions.

Purpose of the Study:

• To generalize the healthy context paradox concept to mediational relationships and cluster-level interventions.
• To propose and test statistical models for identifying the healthy context paradox using multilevel mediation.
• To explore structural and individual-level explanations for the paradox.

Main Methods:

• Two multilevel mediation models were estimated using data from the INCLUSIVE trial.
• Models examined bullying victimization as a mediator and mental wellbeing as an outcome.
• Intervention assignment and mediator-outcome relationships were analyzed at school and student levels.

Main Results:

• Neither proposed statistical model indicated the INCLUSIVE trial exemplified the healthy context paradox.
• Each model offered distinct interpretations relevant to a multilevel understanding of the paradox.

Conclusions:

• Further investigation into intervention harms, particularly for subgroups, is crucial for understanding intervention efficacy.
• The proposed statistical models offer tools to assess and improve intervention development for equitable population outcomes.