Indigenous Models of Evidence-Based Practice

Oregon’s Tribal Best Practices Initiative

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Presenters

One Sky Center

• Douglas A Bigelow, PhD

• R. Dale Walker, MD, (Cherokee)

• Michelle J. Singer, BA (Navajo)

DHS/AMH• Caroline M. Cruz, BS, CPS, CPM

(Warm Springs)

• John Spence, MSW, PhD (Gros Ventre)

• Jason Yarmer, BS, CPS (Chippewa)

Indigenous Evidence-Based Practice 2

•Burns Paiute Tribe•Cow Creek Band Of Umpqua Indians•Confederated Tribes Of Coos, Lower•Umpqua & Siuslaw•Confederated Tribes Of Grand Ronde

•Coquille Indian Tribe•Klamath Tribes•Confederated Tribes Of Siletz•Confederated Tribes Of Warm Springs•Confederated Tribes Of Umatilla

The Nine Tribes of Oregon

04/19/23

The Scenario

• Mandate: Evidence-based Practices

• Problem: bad fit of EBP in Indian Country

• Response: Tribal Best Practices Initiative1. Understand Culture-Based Practice2. Design Tribal Best Practice Process3. Implement TBP Initiative

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Government Office of Money

In God we trust,

…others please provide

Evidence!Indigenous Evidence-Based Practice 504/19/23

THE EVIDENCE-BASED PRACTICE MOVEMENT

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The EBP Movement Matures• What EBM is, and what it isn’t (BMJ)

– Expertise plus research

• Multiple streams of evidence (COCE/SAMHSA)– Experience + client factors + research

• Learning healthcare system (IOM)– Continually increasing knowledge and skill

• Best Practices = – Science + Service+ Indigenous knowledge

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Evaluability

• Program planning and evaluation– (repertoire of techniques)

• Program theory and clarification

• Input-process-outcome

• The Logic Model

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SERVICE TO SCIENCE: WHAT SERVICE KNOWS BEST

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Service-Based Knowledge Addresses Critical Context

• Rural vs. urban setting• Resources (electricity; water)

• Physical condition of participants• Spiritually- vs. materially-oriented participants• Belief of participants• Belief of personnel

• Context and culture

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Service-Based Knowledge Addresses Crucial Behavioral Health Variables

• Choice

• Self-healing belief guided by expert healer

• Unique interpersonal relationships

• Complex webs of inter-related and reciprocal factors

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Service-Based Evidence: The Refinement Process

• Assembled experts

• Published research

• Practice experiences

• Debate quality and meaning of info

• Formal consensus process: conclusions

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Service-Based Evidence: Dissemination

• Guidelines

• Standards

• Resource materials

• Strategic plans

• College curricula, courses, texts

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CULTURE-BASED EVIDENCE

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Why Understand Epistemology of Culture-Based Practices?

• Develop new CBP• Validate proposed CBP• Culturally appropriate tests of what works• Cross-walk to EBP and PBP• Disseminate and improve CBP• Empower indigenous knowledge

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Culture-Based Prevention & Treatment: Activities

• Experience, observation, listening, participating

• Traditions, ceremonies, daily observances

• Stories, songs, artwork

• Oral, modeling, practice, animation

• Language, worldview, teachings, experience

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Culture-Based Health Practices: Materials

• Settings

• Dress; Regalia

• Symbols; Graphics; Pictures

• Sensory Substances

• Food

• Fun

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Culture-Based Health Practices: Personnel

• Enthusiasm, confidence• Caring, compassion• Vision, knowledge• Charisma• Credibility• Community status• Peer group status

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Indigenous Health Practices: Immediate (Proximal) Outcomes

• Balance• Connection

– family, culture, community, natural world, spiritual world

• Identity• Meaning • Power and hope• Self-esteem• Community norms, adaptive capacity, sharing

and support

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Indigenous Health Practices: Distal Outcomes (NOMS)

• Reduced morbidity; mortality• Social participation• Reduced ATOD• Employment; education• Well-functioning families• Reduced criminality• Mental health

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THE OREGON TRIBAL BEST PRACTICES INITIATIVE

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Problem with the EBP Mandate• Developer training & fidelity testing: alien

• “Core components” concept: not adaptable

• Exogenous programming: not credible

• Loss of the familiar and accepted

• Personnel, training, and testing capacity: non-extant

• Versus sovereignty and consultation

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Items Described for Tribal Best Practice

• Replications• Culture-based Evidence• Goals • Target population• Risk and protective

factors

• Tribal personnel• Activities• Materials• Optional Elements• Outcomes

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Evidence for Validity of TBPCriteria

• Longevity• Teachings (based on)• Values (based on; incorporated)• Principles (based on; incorporated)• Elder’s approval• Community feedback/evaluation/acceptance• Contribution to advancement of the people

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Tribal Best Practices Under Review

• Horse Program• Storytelling• Basketball Against Alcohol and Drugs (BAAD)• Elder-based Family Mediation• Cultural Sobriety Recognition Dinner• Powwow

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Horse ProgramCultural Evidence: Longevity of the Practice

• Role of horses stretches back several hundred years

• Tribal stories; old pictures of Native Americans and horses; use by plains Indians for hunting, transportation and warfare

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Horse ProgramCultural Evidence: Teachings

• Native Americans learned from animals; animal characters used as teaching tools

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Horse ProgramCultural Evidence: Values

• Respect • Patience • Personal responsibility • Generosity• Communication

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Horse ProgramCultural Evidence: Principles

• Mentoring • Relating with the natural world• Commitment to others• Leadership skills • Being compassionate• Calmness and self-control in presence of

greater power

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Horse ProgramCultural Evidence: Elders’ Approval

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Horse ProgramCultural Evidence: Community

feedback/acceptance

• Individual stories of youth and family• Tribes requesting program• Tribal satisfaction survey• Feedback from referring agent

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Horse ProgramReplications

• Equine assisted psychotherapy (www.eagla.org)

• Mustangs offering hope and renewal (www.charityblosson.org )

• Tribal horse programs in three other locations in OR.

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Horse ProgramGoals

• Criminal behaviors reduced• Mental health problems reduced• Suicide ideation and attempts reduced• School tenure and academic improvement

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Horse ProgramRisk and Protective Factors

• Drug free activity• Involvement in cultural practice• Bonding and positive relationships• Re-uniting with family• Learned patience, respect, personal

responsibility• Academic progress• Recognition

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Horse ProgramPersonnel

• Named, passionate program advocate, promoter, and implementer

• Named individuals trained and experienced with horses

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Horse ProgramKey Elements (Activities)

• Obtain tribal buy-in• Obtain referrals and subject’s buy-in• Incorporate into summer tribal camp• Teach horsemanship• Conduct ceremonies

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Horse Program Logic ModelMaterials

• Special horses • Water, feed, and grain• Corrals, tack, and equipment• Covered arena (preferred) • Round pen

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Horse Program Logic ModelOutcomes

Decrease/Increase(NOMS) Specific Indicator

Avoidable death/Longevity na

Morbidity/health na

Disability/ability Skill; leadership; responsibility; cooperation

Suffering/well-being Feel good about self & life

Isolation/connectedness Involved in community; bonded to role models

Substance abuse/non-harmful or no use Reduced use

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Horse Program Logic ModelOutcomes

Decrease/Increase Specific Indicator

Unemployed/employed Prevocational skills; communication; work ethic; marketable skills

Education failure/success Academic motivation

Dysfunctional/healthy family Family re-unification; de-stressed family

Delinquency/good behavior Not violating probation; better citizenship

Homelessness/stability na

Bad/ Healthy attitude, beliefs, lifestyle Feels better; feels responsible; feels cooperative

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Vision

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Lessons Learned: Plan for Advancing Culture-Based Practices

Objective• Develop a logic model

• Understand evaluability

• Increasing commitment to evaluation

Action• TPB form, suggestions, and

instructions in logic model format

• Goals, activities, and outcomes in measurable terms

• Participation of Tribes in conceptualizing TBP in both C-B and evaluable terms

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