By: Adrian E. Lopez Romero
Edited By: Stephen Shiwei Wang
Introduction
The current funding model for maternal-child health (MCH) programs primarily supports traditional evidence-based practices (EBPs) and research-based programs. While these models provide scientific rigor, they often fail to account for marginalized communities’ cultural contexts, limiting their effectiveness in promoting health equity. Weis states that EBPs “do not typically arise from the real practices of diverse communities, and they may be poorly aligned with cultural norms, unique symptoms, and risk and resilience factors.”1 There are, however, two rising practices to address the shortcomings of the traditional models. Martinez defined Community-Defined Evidence (CDE) as “a set of practices that communities have used and determined to yield positive results as determined by community consensus over time and which may or may not have been measured empirically but have reached a level of acceptance by the community.”2 Lieberman et al. defined Practice-Based Evidence (PBE) as services “accepted by the local community, through community consensus, and address therapeutic and healing needs of individuals and families from a culturally specific framework.”3
Successful examples across the United States show the power of integrating community-defined evidence (CDE) and practice-based evidence (PBE) into health and social service programs. The California Reducing Disparities Project shows that community-led strategies are practical and essential for enhancing health outcomes among underrepresented populations.4 Washington State’s Best Starts for Kids (Best Starts) initiative provides a model of what is possible when funding supports community-driven approaches. By partnering with 376 community-based organizations and supporting community-designed programs, Best Starts has shown that these approaches can enhance service accessibility and build community trust.5 This paper argues for a more equitable funding model that recognizes diverse ways of knowing, ensuring culturally congruent and effective services for all communities.
Background
Traditional funding frameworks focus on programs validated through randomized control trials and other conventional research methods. Although these approaches establish a certain level of accountability and standardization, they often do not connect with or adequately meet the needs of diverse communities. This disconnect can perpetuate health disparities as designers and implementers overlook the needs and strengths of marginalized groups in their solutions. As noted by Tawa, “EBPs typically don’t include cultural variables in research samples, don’t examine the impact of culture on outcomes, and don’t consider context and environment”.6
In contrast, CDE and PBE are grounded in the community’s lived experiences, incorporating cultural knowledge and practices critical for effective health interventions. Community consensus develops these evidence types, reflecting the unique social, cultural, and historical contexts of the populations they serve. Gronkowski and Pakulis emphasize that community-based models can adapt to the needs of their communities, offering flexibility that traditional evidence-based models often lack. They highlight that “community-based models are set apart by their ability to quickly make changes to their format and content in response to that feedback,” demonstrating the value of community-driven design in improving program quality and outcomes.7
Opposition to Fund CDE and PBE Programs
Opponents argue that integrating CDE and PBE into funding decisions could undermine the rigor and accountability of health programs. They claim these approaches are subjective, difficult to standardize, and may lack the robust evidence needed to ensure program effectiveness and quality. Policymakers may worry that broadening the funding criteria could lead to inconsistent program outcomes and reduce confidence in publicly funded services.
Researchers have established EBPs through strict research protocols, including randomized controlled trials and long-term outcome evaluations. These methods aim to minimize bias and provide reliable data on program effectiveness. For example, the Strengthening Families framework relies on protective and promotive factors validated through extensive research to reduce child maltreatment and promote positive outcomes.8 This level of rigor offers policymakers confidence that funded programs will deliver predictable and replicable results.
While traditional EBPs are valuable, they are often not developed with diverse communities in mind, limiting their effectiveness and applicability. Echo-Hawk states that EBPs often fail to include enough representation of ethnic and cultural minorities in research samples, which limits their applicability and acceptability to these communities. Culturally specific practices, often developed by ethnic service providers, receive insufficient research funding, while mainstream organizations frequently lack the cultural humility necessary for effective collaboration. Additionally, she states there is “limited involvement of ethnic and culturally diverse researchers.”9 This gap in representation highlights the necessity for specific interventions that can more effectively address the unique needs of these communities.
Argument
Argument One: A Comprehensive Support System Requires Diverse Evidence
Effective maternal-child health systems must integrate CDE and PBE alongside traditional evidence-based practices. These diverse forms of evidence capture different communities’ lived experiences, making them crucial for developing impactful interventions.
Traditional EBPs often fail to resonate with marginalized communities because they do not reflect their cultural norms or address their needs. CDE and PBE address these shortcomings by incorporating the cultural values and lived experiences of the populations they serve. For example, Native American communities have long utilized traditional practices alongside mainstream medical approaches to address mental health challenges and substance abuse. These practices, rooted in community consensus and historical context, are essential for promoting health and well-being in a culturally relevant way. Echo-Hawk noted that community members, including participants’ families, develop and evaluate these practices. She noted, “If an intervention is cultural, then the evaluation methodology must be based on cultural knowledge.”10 This participatory approach enhances the interventions’ relevance and effectiveness and fosters community trust and engagement.
Gronkowski and Pakulis highlight community-based models’ flexibility and cultural congruence. They note that there are many ways to collect data and evaluate outcomes to meet the community’s needs.11 Traditional metrics alone are insufficient to capture the true impact of the services. For example, Lucero states that “community-defined and practice-based evidence can record relevant community outcomes from Indigenous perspectives in a culturally appropriate manner.”12 These perspectives align with the need for a more inclusive evidence framework that values community knowledge and practice.
Advocates will argue that integrating CDE and PBE into funding decisions promotes health equity by validating diverse knowledge systems and creating more congruent and effective interventions. They will emphasize that this approach fosters trust and engagement within marginalized communities, leading to more sustainable and impactful outcomes.
Opponents may express concerns about the scalability and reliability of CDE and PBE interventions. They may argue that broadening the definition of evidence could complicate funding and evaluation processes. Additionally, they may argue that ensuring the quality and consistency of programs across different communities would be challenging.
Argument Two: Promoting Health Equity and Social Justice
Investing in CDE and PBE is practical and ethical. It will promote health equity and social justice. It validates community expertise and encourages residents to shape health interventions that resonate with their lived experiences.
Powis et al. call for a shift in MCH decision-making. It should center on the values, needs, and expertise of impacted communities. They emphasize that “evidence co-creation is an essential pathway to building and sustaining trust, and its role in strengthening MCH efforts to advance racial and other forms of equity cannot be overstated.”13 This approach ensures that health interventions are effective, culturally congruent, and just.
Supporters will argue that this approach is crucial for addressing systemic inequities and promoting health equity. They will highlight that community-driven models have proven effective in meeting the needs of marginalized populations and that this approach aligns with broader efforts to advance social justice in health care and human services. Powis et al. state that “prioritizing CDE in decision-making could look like allocating funds to a neighborhood resource center to scale up an existing adolescent health initiative.”14 It also means providing communities with the resources to identify local CDE practices. This approach empowers communities to shape and assess health initiatives that resonate with their unique cultural and social contexts.
Opponents may argue that decentralizing decision-making could complicate oversight and accountability, making it harder to ensure consistent standards of care across different communities. They may also express concerns about the evaluation, which often uses qualitative and community-driven measures and lacks perceived objectivity and rigor. This could damage trust in the outcomes and effectiveness of these programs.
Recommendation
Policymakers and funders must invest in CDE and PBE to advance health equity. This inclusive approach will ensure that maternal and child health services are culturally relevant and practical, addressing the diverse needs of all communities. It is time to adopt a hybrid-funding model supporting traditional evidence-based programs and community-driven initiatives. This model should include flexible evaluation frameworks that honor community-defined success indicators and provide capacity-building support for community organizations. We can create an MCH system that serves all families equitably.
This transformation will encourage a more inclusive approach to policy development and resource allocation across other social service areas. As a result, communities will play a more active role in leading and designing programs that impact their lives, leading to more responsive, sustainable, and effective interventions.
Works Cited
[1] Weis, Kim. 2019. Community-Defined Evidence (CDE) Practices and Strategies: Resource Compendium. Mental Health Technology Transfer Center (MHTTC) Network. Published July 17. Accessed September 27, 2024. https://cars-rp.org/_MHTTC/docs/CDE-Evaluation-Resource-Compendium-PS-MHTTC.pdf
[2] Martinez Ken, Callejas Linda, and Hernandez Mario. 2010. Community-Defined Evidence: A Bottom-Up Behavioral Health Approach to Measure What Works in Communities of Color. EBD 1001.indd. engAGE Living Lab. Accessed September 27, 2024. https://nirn.fpg.unc.edu/sites/nirn.fpg.unc.edu/files/imce/documents/Community%20Defined%20Evidence.pdf.
[3] Lieberman, R., C. Zubritsky, K. Martinez, O. Massey, S. Fisher, T. Kramer, R. Koch, and C. Obrocha. 2010. Issue Brief: Using Practice-Based Evidence to Complement Evidence-Based Practice in Children’s Behavioral Health. Atlanta, GA: ICF Macro, Outcomes Roundtable for Children and Families. http://cfs.cbcs.usf.edu/_docs/publications/OutcomesRoundtableBrief.pdf
[4] California Department of Public Health. 2022. “California Reducing Disparities Project Phase 2.” CultureisHealth. Accessed September 26, 2024. https://cultureishealth.org/wp-content/uploads/2023/06/ADA_CRDP_SWE_Full_Report_with_Exec_Summ_PARCLMU_6.1.23.pdf.
[5] Bachtler Shawn, Ford Kahlil, Gratama Candace, Peterson Kari, and Pineda Daniela. 2022. Best Starts for Kids First Levy Evaluation: Executive Summary. King County Government at Washington State. Accessed September 26, 2024. https://cdn.kingcounty.gov/-/media/kingcounty/depts/dchs/beststarts/documents/BSK%20Reports/Best_Starts_for_Kids_First_Levy_Evaluation_Report_Executive_Summary.ashx?la=en&hash=CFAF795CF7091557826181ED9FA9A9A4.
[6] Tawa, Kayla. 2020. Redefining Evidence-Based Practices: Expanding our View of Evidence. CLASP: the Center of Law and Social Policy. Published May 15. Accessed September 27, 2024. https://www.clasp.org/publications/report/brief/redefining-evidence-based-practices-expanding-our-view-evidence/.
[7] Gronkowski, Nadia, and Pakulis, Averi. 2024. Community-Based Home Visiting: Fidelity to Families, Commitment to Outcomes. First Focus on Children & Start Early. Accessed September 25, 2024, from https://www.startearly.org/app/uploads/2024/06/Community-Based-Models-Fidelity-to-Families-Commitment-to-Outcomes-PDF-FINAL-1.pdf.
[8] Browne, Charlyn Harper. 2014. The Strengthening Families Approach and Protective Factors Framework: Branching Out and Reaching Deeper. Washington, DC: Center for the Study of Social Policy. Accessed September 27, 2024. https://cssp.org/wp-content/uploads/2018/11/Branching-Out-and-Reaching-Deeper.pdf
[9] Echo-Hawk, Holly. 2011. “Indigenous Communities and Evidence Building.” Journal of Psychoactive Drugs, 43(4), 269–275. doi:10.1080/02791072.2011.628920.
[10] Ibid.
[11] Gronkowski, Nadia, and Averi Pakulis. 2024. Community-Based Home Visiting: Fidelity to Families, Commitment to Outcomes. First Focus on Children & Start Early. Accessed September 25, 2024. https://www.startearly.org/app/uploads/2024/06/Community-Based-Models-Fidelity-to-Families-Commitment-to-Outcomes-PDF-FINAL-1.pdf.
[12] Lucero, Esther. 2011. “From Tradition to Evidence: Decolonization of the Evidence-based Practice System.” Journal of Psychoactive Drugs, 43(4), 319–324. doi:10.1080/02791072.2011.628925.
[13] Powis, Laura, Grace Guerrero Ramirez, Linda Krisowaty, and Benjamin Kaufman. 2022. “Shifting Power in Practice: The Importance of Contextual and Experiential Evidence in Guiding MCH Decision Making.” Matern Child HealthJ 26 (Suppl 1), 204–209. https://doi.org/10.1007/s10995-022-03457-8
[14] Ibid.
