How SCED can facilitate D&I

Single-case experimental designs and n-of-1 studies are great ways of promoting diversity and inclusion, as well as dissemination and implementation of evidence-based treatments (both often shortened to D&I). These “small sample studies” can help us ensure that evidence-based interventions are meeting the needs of diverse groups of patients. They can also help identify what to change to make these treatments more appealing and easier to follow. And they can help assess how best to roll out these treatments in new settings.

There is risk in thinking an intervention will work the same for all people. For example, in my field of clinical psychology, most evidence-based interventions were developed and tested with white middle-class Americans in mind (often unwittingly). So these interventions reflect the preferences and values of the U.S. white middle class.

These treatments typically emphasize independence and self-determination, which can be at odds with patients whose cultures emphasize collectivism and shared decision making. Forcing such a patient to conform to these values while undergoing treatment makes it unlikely they will want to follow—and thereby benefit from—the treatment.

Wouldn’t it be better to actually understand how to shape the treatment around what the patient needs? Small sample studies with intensive data collection (like from daily surveys and wearable sensors) can shed light on how to improve acceptability of treatment for different patient populations. For example, I can give a patient the treatment as a written set of instructions, and then collect frequent data on outcomes and perceptions of the treatment. Repeating this process can help both of us improve their treatment plan efficiently, saving time and money while getting the patient the best treatment possible.

This deeper grasp of individuals has been the focus of qualitative research for the past few decades as it focuses on gaining “a better understanding of phenomenon through the experiences of those who have directly experienced the phenomenon, recognizing the value of participants’ unique viewpoints that can only be fully understood within the context of their experience and worldview” (source). For example, reflexive thematic analysis, a foundational qualitative method, allows researchers to identify and analyze overall or nuanced themes (patterns) from rich text data collected from a relatively small set of people through interviews or focus groups. We expect that the recognition and prioritization of individual differences and needs through qualitative and quantitative methods will promote and inform more inclusive interventions.

When it comes to rolling out treatments in new settings, small sample studies are also very valuable. Before investing time and energy into implementing a treatment in a new setting, small sample studies can help identify ways the treatment might need to be altered for the setting and/or for the population served. For example, studies implementing psychological treatments in settings often start by interviewing stakeholders (e.g., patients, providers, administrative staff) to ensure the treatment meets their needs and understand any barriers to implementation. Once the treatment is altered as needed, a small sample study can help ensure the alterations were sufficient before conducting large scale implementation, which is time and cost intensive.