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In a national effort towards accountability and effectiveness of health care, the use of evidence-based practices (EBP) is becoming the standard for clinical care. Every health discipline has examples of historical treatment approaches (i.e., weve always done it this way) without real evidence that it works. The same trend is occurring in the area of prevention as the United States begins the shift from high cost interventions to preventative care. Unfortunately, the historical treatment and prevention approaches are not always effective and have, at times, resulted in no-improvement at best in some cases and fatalities at worst. The move toward demonstrating evidence or research-base of the effectiveness of prevention, treatment and intervention approaches were a step toward ensuring the best possible care for patients and their community. However, as the pendulum swings toward the sole use of clinical practices with formalized research base, new challenges and limitations have emerged, especially for ethnic minority populations and the historically underserved groups of people.
Currently, there are concerns about the cultural competence of some Evidence Based Practices. Many practices that have been determined to be evidence-based have inadequate or no inclusion of cultural variables in research samples, no examination of the impact of culture(s) on outcomes, no adequate consideration for co-occurring disorders, and not taking into account context and environment (Isaacs et al., 2005). This has created difficult for many American Indian and Alaska Native communities trying to implement a practice that has never been tried and tested within Native communities. Further, there is such diversity among Native communities within the United States (including diversity among urban Indian communities) that even if a practice had been appropriately researched and implemented it may not work for all.
To address some of these concerns many native researchers have began to develop and research evidence-based-practices that have been culturally adapted to better suit the needs of many Native Communities. Additionally, the concept of Practice-Based-Evidence (PBE) is becoming common language and represents practices that come from the local community. PBEs are embedded in the culture, are accepted as effective by local communities, and support healing of youth and families from a cultural framework (Isaacs et al., 2005). Many of these PBE have been in place for years and for many tribal communities, for centuries. These practices do not have a research base as we define research today; but they do have an evidence base developed from multiple trials of experimenting with what work best. PBE are effective in supporting healing and wellbeing within the tribal communities from which they evolved and toward whom they are intended. Many of these practices have never undergone any degree of clinical trials however they have survived the test of time research.
Unfortunately, both Culturally Adapted EBP and PBE models have a number of challenges that may limit their application. For an EBP, once a practice has been changed or modified, the practice is no longer being implemented the exact way it was originally researched. Stated another way, once you change an Evidence-Based-Practice it is no longer evidence-based because you have actually changed the practice by making adaptations and modifications. If you are not implementing the practice exactly the way it was intended as an EBP, then you must research the practice with the adaptations to make sure its still showing good outcomes.
Many believed that Practice-Based-Evidence models, grounded in the context and culture of a community, would be a good alternative to EBPs and culturally adapted EBPs. PBEs certainly have the advantage in that they are typically very culturally competent if they were truly developed from local community norms and values. However, PBEs suffer from an overall lack of research resources and appropriateness. Documenting certain culturally-based interventions may be considered inappropriate, depending upon the community cultural values, spiritual teachings, and history. Unfortunately, many tribal communities have a history of researchers documenting their practices from a cultural lens that did not fully appreciate what the practice was as well as the cultural context of a practice, resulting in inappropriate assumptions and misinterpretations. The consequences for these misunderstandings were very significant for tribal communities as many were forced to hide or deny some of these practices for fear of persecution. But even if Native communities decided to engage in research, clinical trial research for PBE models is often not possible for tribal communities that have no research infrastructure (i.e., research training, staff, funding, etc).
Determining what practices are evidence-based or practice-based can be challenging. This is primarily due to the fact that there multiple definitions and criteria for determining each have been proposed, without universally accepted consensus. To add to the confusion, the terms best practices and promising practices have been added to the discussion without good, clear, universally accepted definitions. Although there is a need to for some real dialogue that engage both academia and communities to develop universally accepted definitions and criteria, this type of discussion may take years to resolve. Unfortunately, the health disparate conditions of many of our communities cannot wait as it is costing Indian lives and increasing the risk of more disparities. In the meantime, we must create mechanisms for getting out information about what we know to be of concern and what is currently available now. The term promising practice allow us to accelerate this process by disseminating information as it becomes available. Much of the work in conceptualizing the range of practices within prevention and treatment has taken place within the Substance Abuse and Mental Health Services Administration (SAMHSA). NCUIH uses the following SAMHSA accepted definitions will be used:
Evidence: Refers to data resulting from scientific controlled trials and research, expert or user consensus, evaluation, or anecdotal information.
Evidence-Based Practices: Practices that integrate the best research evidence with clinical expertise and patient values.
Practice-Based Evidence: A range of treatment approaches and supports that are derived from, and supportive of, the positive cultural of the local society and traditions.
Best practices: Most often is used to describe guidelines or practices driven more by clinical wisdom, guild organizations, or other consensus approaches that do not necessarily include systematic use of available research evidence.
Promising Practices: Clinical practices for which there is considerable evidence or expert consensus and which show promise in improving client outcomes, but which are not yet proven by the highest or strongest scientific evidence.
Further, NCUIH evaluates best practices on additional criteria:
Sustainability: Clinical practices that can be sustained over time indefinitely. Sustainability includes both financial (i.e., funding, costs, etc) and human resources (i.e., community engagement, workforce, leadership, etc). Sustainable program restore faith to Indian people that quality services and supports will be there for generations to come.
Replicability: Clinical practices that can be replicated in other communities. Replicability allows for communities to learn and grow from one another and allows for widespread use of effective practices.
Cultural Context: Clinical practices that are consistent with the cultural beliefs, practices, and norms within the local community context. Culturally-based clinical practices are critical for improving cultural competency in clinical care.
There is much to be learned from both Evidence-based-practices and Practice-based-Evidence approaches. While EBP allows for accountability to consumers, their families, and the communities in which they live, PBE allows for the cultural context and characteristics that represents those consumers, families, and communities. While EBP moves toward the replicability of practices so that they are more consistently implemented, PBE allows for practices that match the community context. These two approaches to clinical care are more than just two ends of the same coin, but rather, represent two differing orientations to what is viewed as effective and helpful aspects within specific parameters, with ultimately the same goal- improving the lives of those served. Finding a way to advance both EBP and PBE simultaneously as well as understanding how each compliments the other will be critical for addressing health disparities for American Indian and Alaska Native people.
Bartgis, J., & Bigfoot, D. (2010) full article published in the National Indian Health Board Edition, Healthy Indian Country Initiative Promising Prevention Practices Resource Guide.
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Dolores Subia BigFoot, PhD, is an enrolled member of the Caddo Nation of Oklahoma and is an Assistant Professor of Research in the Department of Pediatrics. Dr. BigFoot is the Director of Project Making Medicine, a national training program for mental health providers in the treatment of child physical and sexual abuse and the newly funded Indian Country Child Trauma Center that is part of the National Child Traumatic Stress Network. Dr. BigFoot is a doctoral-level counseling psychologist and provides consultation, training, and technical assistance to tribal, state, and federal agencies; mental health and family service agencies; and Indian Head Start programs in 22 states. Dr. BigFoot is recognized for her efforts to bring traditional Indian practices and beliefs into the formal teaching and instruction of Indian people and professionals working with Indian populations. Dr. BigFoot provides clinical services in treatment of adolescent sex offenders and Parent Child Interaction Therapy.
Dr. Jami Bartgis completed her Ph.D. in Clinical Psychology at Oklahoma State University and APA predoctoral internship at the University of South Florida, Florida Mental Health Institute, with a focus on mental health policy. She is an enrolled citizen of the Cherokee Nation in Oklahoma and has spent the last 10 years providing behavioral health services to both tribal and urban Indian individuals and communities. Dr. Bartgis is currently the Director of Technical Assistance and Research at the National Council of Urban Indian Health. She served for 3 years in clinical practice at the Indian Health Care Resource Center of Tulsa prior to coming to NCUIH. As a part of practice in Tulsa, she coordinated the SAMHSA Circles of Care grant with the Tulsa urban Indian community, Co-chaired the Tribal/State Relations Workgroup through the Oklahoma Governors Mental Health Transformation Advisory Board, and had the honor of working with countless Indian youth and families both in direct patient care and in the development and advocacy of mental health systems to directly affect the health of the patients she served. Dr. Bartgis currently works to provide technical assistance support to the Urban Indian Health Programs across the US to both improve quality of care and to expand the capacity to provide health services to American Indians and Alaska Natives living in cities.