Dismantling Racism in Public Health: Reconsidering the Role of Evidence
August 2020

Audrey Loper, W. Oscar Fleming

In response to the deaths of Eric Garner and Michael Brown, García and Sharif (2015) wrote that “these preventable deaths were only two recent examples of the stark racial injustices that have plagued our country’s history.”[1] Sadly yet predictably, these words still ring true today. The authors go on to note that public health is fundamentally anti-racist work: Racism is a social determinant of health, and thus a public health issue.1 However, public health is a system, too, and therefore not immune to structural racism. 

In an effort to improve population health outcomes, public health has focused on the expanded use of evidence-based strategies. However, by framing academic evidence as superior to community-defined evidence, we may be perpetuating racism. As Kirkland (2019) notes, “it would be naïve to consider the use of research evidence as a neutral act.”8 Objectivity is not possible given the racism that it is embedded in all of our systems and structures.[2] In fact, given the extent to which racist ideologies were published and then validated by excluding minority voices, research evidence is itself a system of power.2,[3]  

The absence of minority voice and involvement contributes to a poor fit between some evidence-based strategies, on one hand, and a community’s needs and assets, on the other.[4],[5],[6],[7] For example, successful implementation of an evidence-based strategy may require resources and infrastructure (e.g., staffing) that are not available in the community. Furthermore, poor fit may exacerbate inequities in health outcomes, as communities will not engage in programs that do not appeal to them.  

In response to these challenges, we propose greater appreciation for and engagement with community-defined evidence. Drawing on the principles and practice of community-based participatory research[8] and equitable implementation[9],[10] we seek a renewed commitment and expanded effort to place the voices and experiences of People of Color and other marginalized groups on equal footing with researchers and program developers, who are often White and in positions of power.  

MCH professionals and programs can play a central role in strengthening the community’s capacity to identify, evaluate and deliver existing, culturally relevant programs. Regular needs assessment and planning processes, such as the annual Title V block grant process, can be an effective vehicle for this work. However, these processes must be inclusive, welcoming and safe for all. In addition, they must integrate tools that foster critical thinking and input from all participants. The National Implementation Research Network’s (NIRN) Hexagon Tool[11] can be used by communities to have deliberate conversations about existing needs and assets and the extent to which programs or practices fit with their context. The Hexagon is currently undergoing revisions with the support of JustPartners, Inc. to include considerations of race equity, particularly around the value of practice-based and community-defined evidence. In factoring the evidence of a program’s effectiveness, practice-based and community-defined evidence are lifted up as valuable data for making decisions about whether or not to move forward with implementation. 

One case example for considering evidence is the selection of teen pregnancy prevention programs. There are currently a number of evidence-based programs (EBPs) listed on federal registries, but many communities struggle to implement these programs with fidelity. Requirements for condom demonstrations are often a challenge, particularly when implementation occurs in school settings. In these cases, selecting a program that has a less robust research evidence but more practice-based evidence from a similar implementation context could be the best solution for achieving outcomes with young people.  

When EBPs are too challenging to implement, their intended benefits cannot be experienced. By creating a space for practice- and community-based evidence, programs may have greater reach, and therefore a greater possibility of addressing disparities in outcomes. This shift in thinking about evidence is an opportunity for public health practice. By acknowledging that communities, especially communities of color, are the experts about their lives and what strategies best meet their needs, valuing practice-based and community-defined evidence is a point of departure for informed action to address racism and its effects. 

 [1] Garcia, J.J., and Sharif, M.Z. (2015). Black Lives Matter: A Commentary on Racism and Public Health. American Journal of Public Health, 105(8): e27-30. 

[2] Kirkland, D. E. (2019). No small matters: Reimagining the use of research evidence from a racial justice perspective. New York: William T. Grant Foundation.

[3] Ford, C.L., and Airhihenbuwa, C.O. (2010). Critical Race Theory, Race Equity, and Public Health: Toward Antiracism Praxis. American Journal of Public Health, 100(S1): S30-35.

[4] Barth, R.P., Lee, B.R., Lindsey, M.A., Collins, K.S., Strieder, F., Chorpita, B.F., Becker, K.D., and Sparks, J.A. (2012). Evidence-Based Practice at a Crossroads: The Timely Emergence of Common Elements and Common Factors. Research on Social Work Practice, 22(1): 108-119.

[5] Dingfelder, H.E. and Mandell, D.S. (2011). Bridging the Research-to-Practice Gap in Autism Intervention: An Application of Diffusion of Innovation Theory. Journal of Autism and Developmental Disorders, 41(5):597–609.

[6] Flaspohler, P.D., Meehan, C., Maras, M.A. and Keller, K.E. (2012). Ready, willing, and able: Developing a support system to promote implementation of school-based prevention programs. American Journal of Community Psychology, 50:428–444

[7] Ramanadhan, S., Crisostomo, J., Alexander-Molloy, J. Gandelman, E., Grullon, M., Lora, V., Reeves, C., Savage, C., PLANET MassCONNECT C-PAC and Viswanath, K. (2011). Perceptions of evidence-based programs among community-based organizations tackling health disparities: a qualitative study. Health Education Research, 27(4): 717-728.

[8] Jull, J., Giles, A., and Graham, I.D. (2017). Community-based participatory research and integrated knowledge translation: advancing the co-creation of knowledge. Implementation Science, 129(150): 1-9.

[9] DuMont, K., Metz, A., and Woo, B. (2019). Five Recommendations for How Implementation Science Can Better Advance Equity. Academy Health Blog Post. https://www.academyhealth.org/blog/2019-04/five-recommendations-how-implementation-science-can-better-advance-equity

[10] Woo, B., DuMont, K., and Metz, A. (2019). Equity at the Center of Implementation. Center for the Study of Social Policy Blog Post. https://cssp.org/2019/12/implementation-equity/

[11] Metz, A. & Louison, L. (2018) The Hexagon Tool: Exploring Context. Chapel Hill, NC: National Implementation Research Network, Frank Porter Graham Child Development Institute, University of North Carolina at Chapel Hill. Based on Kiser, Zabel, Zachik, & Smith (2007) and Blase, Kiser & Van Dyke (2013).