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Kenneth J. Martinez, Psy.D. Health and Social Development American Institutes for Research

Shaping  Behavioral Health Policy by  Measuring Evidence  in a  New Way : Community  Defined Evidence. Kenneth J. Martinez, Psy.D. Health and Social Development American Institutes for Research March 3, 2014. The Color of America is Changing.

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Kenneth J. Martinez, Psy.D. Health and Social Development American Institutes for Research

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  1. Shaping BehavioralHealth Policy by MeasuringEvidence in a New Way: Community DefinedEvidence Kenneth J. Martinez, Psy.D. Health and Social Development American Institutes for Research March 3, 2014

  2. The Color of Americais Changing Ethnic/Racial Group Population % of Total • White (Non-Hispanic) 202.9 million 63.0% Latino/Hispanic 54.7 million 17.0% • African American 41.3 million 12.8% • Asian American 1 million 5.6% • American Indian/ Alaska Native 4.1 million 1.3% • Native Hawaiian and other Pacific Islander 1.1 million .3% • Bi/multi-racial 6.9 million 2.2% • Other Races/Ethnicities 19.0 million___________ People of Color: >128.2 million/331 million Total: 39% (US Census Bureau 2013) Kenneth J. Martinez, Psy.D.

  3. Kenneth J. Martinez, Psy.D.

  4. The Problem • Disparities in mental health care are widening between whites and people of color, particularly in the areas of access, availability, quality and outcomes of care. Collectively, ethnically/racially diverse populations experience a greater disability burden from emotional and behavioral disorders than do white populations.(Huang, 2002; U.S. Dept. of Health and Human Services [USDHHS], 2001) Kenneth J. Martinez, Psy.D.

  5. Number and Proportion of all Access Measures Kenneth J. Martinez, Psy.D.

  6. Number and Proportion of all Quality Measures Kenneth J. Martinez, Psy.D.

  7. Kid’s Count 2013 Child and teen deaths per 100,000: 2010 Children living in high-poverty areas: 2007–2011 Kenneth J. Martinez, Psy.D.

  8. Alcohol and Drug Abuse Among Youth in U.S. • 6.8% of persons aged 12 or older (an estimated 17.7 million individuals) in 2012 were dependent on or abused alcohol within the year prior to being surveyed. This rate is a decrease from 2008 (7.4%). • 7.7% of persons aged 12 or older who were dependent on or abused alcohol in 2012 (an estimated 1.4 million individuals) received treatment for alcohol use within the year prior to being surveyed. • 9.5% of 12- to 17-year-olds (an estimated 2.4 million youth) in 2012 reported using illicit drugs within the month prior to being surveyed. (SAMHSA, 2013) Kenneth J. Martinez, Psy.D.

  9. Percentages of Youth Ages 12 to 17 with Alcohol Dependence or Abuse in the Past Year, by Race/Ethnicity: 2008-2012 NSDUH Race/Ethnicity % Non-Hispanic 4.1 White 4.7 Black 2.1 American Indian or Alaska Native 6.7 Native Hawaiian/Other Pacific Islander 7.3 Asian 1.6 Hispanic or Latino 4.9 (SAMHSA 2013) Kenneth J. Martinez, Psy.D.

  10. Percentages of Youth Ages 12-17 with Illicit Drug Dependence or Abuse in the Past Year, by Race/Ethnicity: 2008-2012 NSDUH Race/Ethnicity % Non-Hispanic 4.3 White 4.5 Black 3.6 American Indian or Alaska Native 8.8 Native Hawaiian/Other Pacific Islander 4.9 Asian 1.7 Hispanic or Latino 5.2 (SAMHSA 2013) Kenneth J. Martinez, Psy.D.

  11. Major Depressive Episodes (MDE) Among Youth 12-17 Years of Age • From 2008 to 2012, the rate of MDE among U.S. youth increased from 8.3% to 9.1%, (an estimated 2.2 million youth). The rate of MDE increased among Hispanics (from 7.5% to 10.5%) but not among Whites or Blacks. • In the U.S., 37% of youth with MDE (an estimated 813,000 youth) in 2012 received treatment for depression within the year prior to being surveyed. This rate has not changed significantly since 2008. • Hispanic youth who had an MDE in the past year were less likely to have received treatment for depression (30.8%) than White youth (40.7%). (SAMHSA 2013) Kenneth J. Martinez, Psy.D.

  12. Special Analysis for Surgeon General’s Report on Culture, Race and Ethnicity • Between 1986 and 2001, nearly 10,000 participants were included in randomized controlled trials evaluating the efficacy of interventions for four mental health conditions (bipolar disorder, schizophrenia, depression and ADHD) and included only: • 561 African Americans (5.6%) • 99 Latinos (.01%) • 11 Asian Americans and Pacific Islanders (.001%) • 0 American Indians and Alaska Natives were available for analysis. • Not a single study analyzed the efficacy of the treatment by ethnicity or race. (Miranda et al., 2003) Kenneth J. Martinez, Psy.D.

  13. Attempts to Solve the Problem Kenneth J. Martinez, Psy.D. • Evidence-based practice (EBP) • Is the EBP “Gold Standard” culturally appropriate? • Most EBP trials are conducted with White, educated, verbal and middle class individuals and may not generalize to ethnic/racial groups and third world communities (Bernal & Scharron-del-Rio, 2001) • Empiricism (upon which randomized-controlled trials are based) is a western epistemological model

  14. Evidence-based Practices Kenneth J. Martinez, Psy.D. • Do EBPs take the following into consideration? • Historical trauma • Cultural values, beliefs, traditions and preferences • Contextual, transactional and societal variables relating to the emotional and physical environments in which the individual lives • Some do and some do not “The central problem is that treatments that have been validated in efficacy studies cannot be assumed to be effective when implemented under routine practice conditions” (Hoagwood et al., 2001).

  15. Transactional Best Practices for Communities Of Color Methodological Dynamic Ecological Model Transactional Contextual Values Historical Child/Family Kenneth J. Martinez, Psy.D.

  16. Domains and Variables • Values • Cultural beliefs • Spirituality and Religion • Concepts of: • Familismo/Personalismo/Dignidad • Respeto (Respect) • Cultural Humility • Communal vs. Individualistic • Cooperation vs. Competition • Interdependence vs. Independence • Rituals • Traditions • World view • Contextual • SES • Immigration status • Generation in US • Degree of political power • Transnationalism • Geographic region • Cultural knowledge • Acculturation level • Self-identified cultural identity • Heterogeneity within culture • Respect for community knowledge • Setting • Age • Historical • Racism • Ethnocentrism • Colonialism • Displacement • Genocide • Prejudice • Discrimination • Exploitation • Methodological • Paradigm/Conceptualization/ • Epistemology • Empirical • Non-empirical • Qualitative • Pluralistic • Efficacy vs. Effectiveness • Definition of evidence • By whom? • Using what standard? • Compared to what? • Research approach • Traditional (Top down) • Community defined (Bottom up) • Data collection/analysis/interpretation • Translation • Clinician/service recipient match Best Practice for Developing, Adapting, Choosing and Using Evidence Based Treatments/ Empirically Supported Treatments • Transactional • Language • Engagement • Synchronous goals • Relationship • Engaging youth, families, & • service recipient in research • Availability of providers Kenneth J. Martinez, Psy.D.

  17. Granular Ethnicity Ancestry, which the Census Bureau defines as “a person’s ethnic origin or descent, ‘roots,’ or heritage, or the place of birth of the person or the person’s parents or ancestors before their arrival in the United States” is the ethnicity concept adopted by the subcommittee as the level of detail necessary for quality improvement. • Collect granular ethnicity data as a separate variable from the OMB race and Hispanic ethnicity categories • Granular ethnicity categories should be selected from a national standard list (Institute of Medicine, 2009) Kenneth J. Martinez, Psy.D.

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  19. IOM Recommendations for Standardized Collection of Race, Ethnicity, and Language Need Kenneth J. Martinez, Psy.D.

  20. Community Defined Evidence Project (CDEP) Research Questions • Can we identify “effective” community and/or culturally based practices, who is doing them and how they are being done? • What are the common characteristics or “essential elements” among these practices that may help us better define Community Defined Evidence for Latino/Hispanic communities? • Is there formal or informal measurement of effectiveness that is being used with such practices? If so, can we document these measures? • Are there culturally-informed methodologies and measurement practices that involve the community? Kenneth J. Martinez, Psy.D.

  21. Community Defined Evidence • A research model that emphasizes investigation “from the ground up” (Martinez et al., 2010). • A basic tenet of CDE is that service recipients have knowledge based upon life experience and learned expertise that is rarely tapped to inform scientific study, especially in developing behavioral health practices. • CDE seeks to identify and affirm alternative and existing forms of knowledge about behavioral health and wellness and to use traditional and indigenous ways of knowing to develop and implement practices that are ultimately acceptable and useful to the populations that are expected to use them. Kenneth J. Martinez, Psy.D.

  22. Community Defined Evidence Initial Working Definition • CDE is a set of practices that have been found to yield positive results as determined through ongoing efforts to achieve community consensus, and which have reached a level of acceptance by service recipients despite varying degrees of empirical measurement of practice effectiveness. (2012) • A complementary approach to EBPs Kenneth J. Martinez, Psy.D.

  23. CDEP Community Steering Group Kenneth J. Martinez, Psy.D. Composed of family members, youth leaders, consumers, disparities researchers, practitioners and policy makers Provided input on developing methods that facilitate community participation (nomination process, site selection process) and reviewed information gathered

  24. CDEP Practice Selection Kenneth J. Martinez, Psy.D. • Call for nomination of practices • Criteria used to identify practices: • Knowledge of the population(s) of focus • Clear articulation of practice • Evidence of practice utilization • Potential for demonstrating outcomes • Demonstrated (or potential) sustainability of practice and related outcomes

  25. CDEP Data Collection Kenneth J. Martinez, Psy.D. • Site visits • Telephone interviews • 11 to 21 in depth interviews conducted for qualitative analysis with stakeholders at each site (246 interviews completed) • Cross-section of organizational staff • Service recipients and family members and • Community partners • Survey questions to record demographic data and perceptions related to culturally responsive service delivery

  26. Criteria Used to Review Identified Practices • 1. A process that includes the community • 2. Develop a practice with community involvement and expertise • 3. Test and implement the practice, including community input • 4. Assess implementation and utilization of the practice • 5. Continuous quality improvement process Kenneth J. Martinez, Psy.D.

  27. Types of Community or Culturally-Based Practices Identified 1.Capacity-building and consciousness-raising 2. Raising public awareness about mental health 3. Community outreach 4. Increasing service accessibility Kenneth J. Martinez, Psy.D.

  28. Types of Community or Culturally-Based Practices Identified 5. Innovative engagement practices 6. Organizational practices 7. Local adaptations of EBPs for Latinos 8. Interventions and therapies Kenneth J. Martinez, Psy.D.

  29. Essential Elements (Common Characteristics) Across Practices • Acknowledging the centrality of the family • Creating and encouraging a collective healing process • Addressing needs holistically • Addressing stigma and using culturally relevant terms Kenneth J. Martinez, Psy.D.

  30. Essential Elements (Common Characteristics) Across Practices 5. Engaging in dialogue about the practice with community members and service recipients on an ongoing basis 6. Increasing community connections by partnering with organizations important to local Latino/ Hispanic communities 7. Implementing practice in comfortable and familiar practice settings Kenneth J. Martinez, Psy.D.

  31. Organizational Factors that Facilitate CDE • Flexible organizational structure • Partnerships • Key figure or champion • Advocacy role Kenneth J. Martinez, Psy.D.

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  33. Community Defined Evidence Examples • Therapeutic Drumming – San Francisco, CA • Enlace Comunitario - Albuquerque, NM • Bienvenido Program - Lingonier, IN • Sisters of Color United - Denver, CO • Comunilife - New York City, NY • Hoy Recovery Program - Espanola, NM • Chemical Abuse Services Agency - Bridgeport, CT Kenneth J. Martinez, Psy.D.

  34. Policy, Research, and Practice Conclusions • Proceed with caution • Consider ESTs/EBTs/EBPs/CA-EBTs/PBE/CDE all as options • Cost is a consideration • Let’s not be “empiri-centric”! • Include, and not dismiss, practices that have “worked” in communities • We need to discover and/or develop the evidence • Consider a new measuring stick, “platinum standard” Kenneth J. Martinez, Psy.D.

  35. Next Steps Share the knowledge gained Engage families, youth and communities Influence policy efforts Refrain from “legislating” types of practices that will be funded Advocate for “effectiveness” measures that are culturally and community appropriate Kenneth J. Martinez, Psy.D.

  36. Gracias

  37. References Kenneth J. Martinez, Psy.D. Agency Healthcare Research and Quality, 2012 National Healthcare Quality and Disparities Report. Annie E. Casey Foundation, Kid’s Count Data Book: State Trends in Child Wellbeing (2013). Bernal, G. & Scharron-del-Rio, M.R. (2001). Are empirically supported treatments valid for ethnic minorities? Toward an alternative approach for treatment research. Cultural Diversity and Ethnic Minority Psychology,7: 328-342. Hoagwood, K., et al. (2001). Evidence-based practice in child and adolescent mental health services. Psychiatric Services, 52:1179-1189. Huang, L. (2002). Reflecting on cultural competence: A need for renewed urgency. Focal Point, 16 , 4-7. Martínez, K.J., Callejas, L., Hernandez, M. (2010) Community-Defined Evidence: A bottom-up behavioral health approach to measure what works in communities of color. Emotional and Behavioral Disorders in Youth. Volume 10, No. 1. Civic Research Institute, Kingston, N.J.

  38. References Miranda, J., Nakamura, R., & Bernal, G. (2003). Including ethnic minorities in mental health intervention research: A practical approach to a long-standing problem, Culture,Medicine & Psychiatry, 27 , 467-486. Substance Abuse and Mental Health Services Administration. Behavioral Health Barometer: United States, 2013. HHS Publication No. SMA-13-4796. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013. U.S. Department of Health and Human Services .(2001). Mental health: Culture, race, and ethnicity – A supplement to mental health: A report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services. Kenneth J. Martinez, Psy.D.

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