One Sky Center R. Dale Walker, MD, Director Michelle Singer, Communications Coordinator, ICMI Project Director Doug Bigelow, PhD, Deputy Director.

One Sky Center

R. Dale Walker, MD, DirectorMichelle Singer, Communications Coordinator, ICMI Project DirectorDoug Bigelow, PhD, Deputy Director

Evidence-Based vs Culture-Based Dilemma

What is “Evidence”?

Multiple Streams of Evidence

The Learning Healthcare System

Description: A Scientific Framework

Some Culture-Based Interventions

Epistemological gulf Western Traditional AI/AN

Epistemological debate Validity of traditional world view Freedom to live by a traditional world view

Practical debate Controlling by purse strings

Bridging Evidence is? Status of evidence for EBI How to meet reasonable standards of

evidence

Practice Improvement Multiple Streams of Evidence Learning Healthcare System

http://coce.samhsa.gov/cod_resources/PDF/OP5-Practices-8-13-07.pdfhttp://www.iom.edu/CMS/28312/RT-EBM/41894.aspx

1. Intervention/program research Randomized Controlled Trials (RCT) Nonrandomized, uncontrolled Evaluation

Adaptation of Proven Intervention Like a Proven Intervention Basis in Proven Theory, Principles, Facts

Criteria: Fidelity Internal Validity (vs confounding variables) External validity Reliability—repeatability.

Process: Scientific experts Independent judging and rating Compilation and Summary

Therapeutic power of Choice

Self-healing guided by expert healers

Uniqueness of interpersonal relationships

Complexity of factors

1. Individual studies

2. Reviewed collections

3. Lists of model, best, promising, alternative

4. Survivors of meta-analyses

“Best Practices” = highest scientific standards

Balance point Reasonable standards are:

Repeatability Achievable within resources and constraints Allow conclusions without intolerable doubt Low risk of harm, if conclusions are wrong

Adoption requires buy-in

Acceptance Implementation

Adaptation to unique local culture and context

Players Rules, expectations, traditions Resources/collaborations Opportunity to contribute to strategic plan

MI, CBT, SFP, Project Venture, Canoe Journey implementations are unique in every setting

Every replication is an Adaptation

The EBI idea is changing

SAMHSA: “multiple streams of evidence”

IOM: “Learning Healthcare System”

Intervention/program RTC; Evaluation

1. Adaptation of Proven Intervention

2. Analogous to a Proven Intervention

3. Basis in Proven Theory, Principles, Facts

1.Causes

2.

TargetPopulationFor intervention

Intervention

Outcome

Domains:Individual

RelationshipCommunity

Culture

8. Long term

7. Medium term

6.Short term

5. Manual

4.Theory of Action

3. Intervention

strategy

“Operationalization” a way of knowing/believing From black box to detail

Consistency with body of knowledge

Who, what, when, where, how, decisions Repeatability

Social ecology (influences)

Prevention Universal/ selected/

indicated

Risk and Resilience Readiness to

Change Risk taking/seeking Stress vulnerability

Modeling (observational learning)

Instrumental learning Group dynamics Conformity, altruism Listening and support Catharsis Psychopharmacology

• Screening• Gatekeeping• Diagnosis• Treatment• Traditional healing• Traditional

ritual/ceremony• Postvention• Parent/family training• Group work

• School/institution-based• Education/skills• Experiential• Socialization/

acculturation• Public Health

(risk/resilience)

• Services develop/coord• L E/justice/corrections• Community competency• Community change• Culture

Story telling Talking circles Sweat Lodge Ceremonies and

Ritual Purification Passages Naming Grieving

Drumming, singing, dancing

Vision Quest

Flute playing/meditation

Reconciliation

Mentoring

Service learning

GONA

Cultural Enhancement Through Story Telling (Tohono O’odham Res)

AI Strengthening Families Program (U UT)

Across Ages (Mentoring) (Temple U)

Creating Lasting Family Connections Dare to Be You (Ute Res)

With Eagles Wings (N. Arapaho Nat)

Families That Care—Guiding Good Choices

Families and Schools Together (Rural Wisconsin Res)

Parenting Wisely Preparing for Drug Free Years Project Alert Project Venture (NIYLP)

Promoting Alternative Thinking Strategies

Zuni Life Skills (Zuni Pueblo)

http://www.spokane.wsu.edu/ResearchOutreach/wimhrt/research2.asp

Deal with Epistemological Gulf Know limitations of Evidence in EBI Agree upon “Practice Improvement”

Goal Make credibility gains with “Scientific

Framework” for Description Use existing practices and knowledge

as evidence for similar CBI

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