Imported “Evidence-Based” or Locally Grown Interventions: A False Dichotomy and Some Hard Choices in Implementation Science

Abstract

When public health programs are expanding to new areas or territories, it is often recommended by policy-makers and donors that existing evidence-based practices (EBPs) are to be adapted and implemented. While rationale behind this approach is understandable, proper adaptation to culturally different settings may be no less intensive than development of a new intervention based on the local context. A narrow understanding of implementation science concept may lead to overlooking valuable indigenous practices, which may be summarized into effective and potentially more sustainable models. This paper examines from practical standpoint the process and common caveats in cross-cultural adaptation of EPBs and argues for closer attention to available local experiences.

Keywords:

• evidence-based practices
• evidence-based interventions
• implementation science
• Ukraine
• drug abuse
• HIV/AIDS

Notes

¹ Treatment can be usefully defined as a unique, planned, goal-directed, temporally structured, multi-dimensional change process, which may be phase-structured, of necessary quality, appropriateness, and conditions (endogenous and exogenous), implemented under conditions of uncertainty, which is bounded (culture, place, time, etc.), can be (un)successful (partially and/or totally), and being associated with iatrogenic harm. It can be categorized into professional-, tradition-, mutual-help-based (AA, NA, etc.) and self-help (“natural recovery”) models. Whether or not, a treatment technique is indicated or contraindicated, and its selection underpinnings (theory-, empirically-, “principle of faith-”, tradition-, budget-based, etc.) continues to be a generic and key treatment issue. In the West, with the relatively new ideology of “harm reduction” and even newer “Quality of Life” (QOL) and “wellness” treatment-driven models, there are now new set of goals in addition to those derived from/associated with the older tradition of abstinence-driven models. Conflict-resolution models may stimulate an additional option for intervention. Treatment is implemented in a range of environments, ambulatory as well as within institutions, which can also include controlled environments such as jails, prisons, and military camps. Treatment includes a spectrum of clinician–caregiver–patient relationships representing various forms of decision-making traditions/models: (1) the hierarchical model in which the clinician–treatment agent make the decision(s) and the recipient is compliant and relatively passive; (2) shared decision-making, which facilitates collaboration between clinician and client(s)/patient(s) in which both are active; and (3) the “informed model,” in which the patient makes the decision(s). Within this planned change process, relatively recently in various parts of the world, active substance users who are not in “treatment,” as well as the users who are in treatment, have become social change agents, active advocates, and peer health counselors … which represent just a sampling of their new labels. There are no unique models or techniques used with substance users–of whatever types and heterogeneities–which aren't also used with non-substance users. The reality that substance users, representing a heterogeneous group of people, patterns of use, and life styles, continue to be treated in “specialized” programs which are distanced from the mainstream of the treatment of non-users— “Normed Treatment of Normed Diseases”-–and all-too-often manifest imparity in availability, accessibility, and delivery of needed services, utilize policies which are stakeholder-–driven and not evidence-based and may be ethically insensitive, does not change the reality that there is no “drug treatment;” no “alcohol treatment.” Editor's note.

² This overview does not include, although highlights, the need for an analysis of the roles of influential individual and system stakeholders as institutional barriers, as well as “bridges” or enablers, to needed changes, similar to the one published by Thom (2013). Editor's note.

³ The reader is asked to consider the implications of the semantics of substance use(r) interventions, its underpinnings of consensualizations, which may or may not be generalizable, and ongoing processes of too-early closure, in which description becomes valid explanation, statistical significance becomes substantive significance and peer review, and a publication's high impact factor becomes a “gold standard” for measurable expertise and quality. For example, a stimulating analysis about purported “cause and effect” is presented by Hills's criteria for causation which were developed to help assist researchers and clinicians determine if risk factors were causes of a particular disease or outcomes or merely associated. (Hill, 1965). Evidence-based/informed, as a concept, an outcome of a scientific investigative process, associated as it is with fact, is affected by a binary bias as well as it not transmitting a nuanced dimension. Editor's note.

⁴ The reader is referred to Keil's concept of an “illusion of explanatory depth;” a superficial understanding of how complex systems work while feeling that we do understand…until we are asked to explain how it works…confronting us with how little we actually know (Keil, 2006). Editor's note.

⁵ A caveat is called for at this point. Just as the General Semanticists reminded us that the map is not the territory, recognized, consensualized principles are no more, or no less, than the interacting internal and external constraints and “flaws” of being capable of human awareness, expectations, perceptions, judgments, decision-making, which is or isn't implemented and is or is not learned from, as well as becoming and being engaged by the challenges and the opportunities presented by intervention, unfinished business. Editor's note.

Additional information

Notes on contributors

Kostyantyn Dumchev

Kostyantyn Dumchev, MD, MPH, Ukraine, is a scientific director at the Ukrainian Institute of Public Health Policy. He conducts research in the areas related to substance use and HIV/AIDS, including epidemiology, estimation, and program effectiveness. His previous experience includes the transfer of behavioral treatments for substance abuse to Ukrainian public clinics, evaluation of medication-assisted treatment, studies on new trends in drug scene, and determinants of HIV status in people who use drugs. Dr Dumchev is a long-time member of the Inter-sectoral Monitoring and Evaluation Workgroup, overseeing research and evaluation activities related to HIV response in Ukraine. His main current projects are the HPTN protocol on effectiveness of HIV treatment among people who use drugs, and the prospective study of HIV incidence among clients of harm-reduction programs in Ukraine. Dr Dumchev received his MD from Vinnitsya National Medical University, and MPH from University of Alabama at Birmingham.