Intersecting Evidence Based Practice and Cultural Competence

1. Intersecting Evidence Based Practice and Cultural Competence Oregon Juvenile Department Directors’ Association Annual Conference Jennifer L. Bellamy

2. Areas of Interest and Experience • Research and training to support EBP in Social Work • Adapting child and family interventions to better engage fathers

3. Why this Intersection? • Uptake of scientific discoveries into practice is estimated to be 14% after 17 years • Huge investment in intervention research • Diversity of the US Population • Services and outcomes disparities • Prioritization of reducing service disparities and evidence based practice

5. The Intersections • Research evidence and diverse populations and contexts • Adaptation to evidence-supported interventions • The evidence on culturally competent practice

6. Top Down EBP • Select “evidence based” practices (packages, programs, guidelines) are: • Mandated by policy • Required for funding • Chosen by individual providers • Implemented by program directors and administrators

7. Top Down EBP • Evidence Supported Interventions • Examples: Trauma Focused Cognitive Behavioral Therapy (TF-CBT), Multisystemic Therapy (MST), Parent Child Interaction Therapy (PCIT) • Practice Guidelines • Implement the Practice with as much Fidelity as Possible

8. Lists and Criteria • SAMHSA’s National Registry of Evidence-Based Programs and Practices • California Evidence Based Clearinghouse (Child Welfare) • States and Counties • Funders • Service Providers

9. Top Down Benefits • Great deal of thought and research into the development of ESIs and guidelines • Well articulated training, manuals, and supervision structures • It’s a relatively intuitive approach to EBP

10. A Popular Approach • Arguably the most common strategy to EBP. • Make lists of effective ESIs or practice guidelines and understand “good practice” that way

11. Chorpita July 2010 ACME Evidence- Based Treatment Manual

13. ACME Evidence- Based Treatment Manual

14. ACME Evidence- Based Treatment Manual

15. Common Questions • “How can I learn enough ESIs?” • “Aren’t there other forms of evidence?” • “What about what I was doing before?” • “How will what I learn stay current?” • “Are there ESIs for all the different kinds of kids we work with? • “What do I do if there are not?” • “What do I do if a child does not respond to an ESI?” Chorpita July, 2010

16. Top Down Challenges • Local context • Intervention studies aren’t the only source of evidence • These lists obscure the details in the research that providers might find useful • These products are intended for a group, not an individual client • Our best interventions don’t work for everyone

17. Bottom Up EBP • A process or series of steps • Lots of different types of evidence are included • Clients are engaged in a process of decision making • The service provider brings it all together

18. Bottom Up EBP

19. In Contrast to Top Down • ESIs can be implemented, but other types of research evidence and other types of evidence are also explicitly considered on a case-by-case basis.

20. “Good to see you, Sally. As soon as I finish reading these research studies, we can start our session today.” Data Overload Chorpita, July 2010

21. Bottom Up Challenges • It’s difficult to slog through all of the evidence out there • There isn’t a lot of guidance on how to translate and implement findings in practice • Whole new science of implementation

22. Intersection #1 • Research evidence and diverse populations and contexts The historical exclusion of diverse populations in research and the lack of attention to issues of cultural diversity contributes to the poor uptake of research evidence into practice.

23. The Gaps • There are gaps in the research evidence. We have less to offer: • Children and families of color • Rural service settings • Children and families with multiple problems

24. An Example • Child and Adolescent Treatment Research • 457 randomized clinical trials • 45 years • 1,138 study groups • 43,091 youth participants • > $1B in today’s dollars Chorpita, July 2010

25. Search #1 • What treatments are successful with: • Disruptive behavior problems • Children and adolescents • Any ethnicity • Male or female • “Good” research support • At least one study showing the interventions is better than another treatment or placebo, or equivalent to an established intervention

26. Results • Papers: 83 • Top 3 Most Successful Treatments: • Parent Management Training: 42% • Multisystemic Therapy: 9% • Anger Control Treatment: 7% • Settings: • Most common, clinics: 40% • Corrections: 9%

27. Search #2 • What treatments are successful with: • Disruptive behavior problems • Adolescents (15 years old) • Any ethnicity • Male or female • “Good” research support

28. Results • Papers: 30 • Top 3 Most Successful Treatments: • Multisystemic Therapy: 19% • Communication Skills: 14% • Anger Control Treatment: 8% • Settings: • Most common, schools: 39% • Corrections: 25%

29. Search #3 • What treatments are successful with: • Disruptive behavior problems • Adolescents (15 years old) • Black or African American • Male or female • “Good” research support

30. Results • Papers: 17 • Top 3 Most Successful Treatments: • Multisystemic Therapy: 37% • Assertiveness Training: 16% • Anger Control Treatment: 11% • Settings: • Home: 39% • Corrections: 26%

31. Search #4 • What treatments are successful with: • Disruptive behavior problems • Adolescents (15 years old) • Black or African American • Female • “Good” research support

32. Results • Papers: 6 • Top 3 Most Successful Treatments: • Multisystemic Therapy: 50% • Assertiveness Training: 17% • Rational Emotive Therapy: 17% • Settings: • Community: 50 • Home: 50 • Corrections: 0%

33. Other Searches • Native American adolescent females with disruptive behavior problems: 1 paper • Asian adolescent males with disruptive behavior problems: 2 papers

34. The Fit Problem • Many interventions have been developed for, and tested with, limited populations in limited contexts. • Even when you expand beyond the most sophisticated intervention trial research, there isn’t as much research specific to racial and ethnic minority groups

35. The Good-ish News • This problem is being addressed– more and more research is inclusive of diverse populations • However, we don’t have the luxury of waiting.

36. What can we do? Some approaches to address the lack of fit: • Try to select the ESI that we think is closest to what we need and use that • Select something that we think fits better, but isn’t an ESI • Conduct more research diverse populations in diverse contexts • Adapt existing interventions

37. Intersection #2 2.Adaptation to evidence-supported interventions When interventions are transported from one service/client context to the next, adaptations are needed to address variation across: client population, organizational context, providers and community context.

38. Reasons for Adaptation • Poverty 25% • Racial/Ethnic Diversity 29% • Rural Location 30% • Gang Activity 32% • Special Needs/Disabilities 37% • Existing Substance Abuse Problem 41% • Youth Violence 46% • Discipline/Behavior Problems 51% Ringwalt et al. 2004

39. Drift Versus Adaptation • Adaptation- when intervention developers make changes to interventions • Drift- when someone else does it

41. Adaptation in Practice • “…common dissemination practices often presume that practitioners are passive recipients of an innovation rather than active participants in the dissemination and implementation process…. practitioners and community members have a wealth of information regarding the populations most in need of EBPs, and that those needs must be taken into consideration in program implementation.” • Lee et al. 2008 p. 298

42. Adaptation in Practice • As we began work on the DEBI project, what was originally described as a process of “technology transfer” soon became a process of “technology exchange.” It became clear that instead of a one–way transfer, success would depend on a multidirectional technology and information exchange that incorporated the experiences and expertise of valued partners with years of experience. • Collins et al. 2006

43. Alternative Definition • Adaptation- changes that are purposeful and evidence driven- and may be directed by researchers or service providers- preferably both • Drift- unplanned changes based on implicit assumptions, entropy, etc.

44. First Big Question 1. Is there a need to adapt? • What constitutes evidence for the need to adapt? • Some studies have found little relationship between students’ ethnic background and program effectiveness (Backer & Diaz, 1999). • How do you know what to adapt?

45. Specifying the Adaptation Problem • Do you see group differences in terms of client uptake? Refusal Attendance Attrition Engagement

46. Specifying the Adaptation Problem • Do you see group differences in terms of treatment response (clinical outcomes)? Speed Strength Durability Generalizability

47. Specifying the Adaptation Problem • Do you see group differences in terms of provider or system feasibility/sustainability? Provider skill Available time Physical space

48. Second Big Question 2. How to adapt? • Who is needed in the adaptation process? • What sources of data are required to guide adaptation?

49. When the intervention, client characteristics, and service context don’t fit Intervention Clients Service Context Cost, Duration, Efficacy Culture, preference, needs Culture, Resources, Staff

50. Adapting the Client • Talk them into what you have to offer • Prepare them for what you have to offer • Entice them