Practice-Based Research From the Frontlines: Selected Strategies for Reducing Health Disparities and Accelerating Progress Toward Health Equity in the United States

Practice-based knowledge refers to unique awareness and understanding acquired as practitioners face public health challenges and create new opportunities for health improvement. ¹ It includes insights from experiences, interactions, and task performance and is co-created as all public health services are delivered. Unfortunately, practice-based knowledge is not always appropriately valued, harnessed, or elevated in the field.^2,3 Practice-based knowledge is amplified and its use is more effective when leveraged within practice-based research, which refers to “systematic inquiry into the systems, methods, policies, and programmatic applications of public health practice.”^4,5 Practice-based research transforms practice-based knowledge and optimizes and sustains its relevance, effectiveness, and impact, enabling the implementation of new insights beyond its original goals.^2,4

Translation of practice-based knowledge from state, tribal, local, and territorial (STLT) and federal contexts of public health practices is more critical than ever given that public health professionals are grappling with systemic challenges, confronting long-standing public health problems, and struggling to promote and protect health among all populations in diverse places and are faced with what some call “cascading collective traumas”: the onset of the COVID-19 pandemic in 2020, an economic recession, structural racism and the organized community response, and weather-related disasters.^6-8 Health disparities and inequities rooted in inequitable distributions of social determinants of health (SDoH) have caused those disparities to become increasingly critical challenges for public health agencies.^9-11

The co-occurrence of these events and the emergence of backlash against public health complicated public health practice and exacerbated systems that were already strained and overwhelmed.^12-14 Such discontent and strain leading to intentions to quit the public health workforce were high among STLT employees who were from racially or ethnically minoritized groups, paid low wages, aged <36 or >65 years, without graduate degrees, and specifically recruited for COVID-19 response. ¹⁵ But these cascading collective traumas also introduced new opportunities to advance health equity as they forced the United States to attend to long-standing structural and social inequities and the creation and persistence of health inequities linked to disparate and disproportionate COVID-19 burdens (eg, in cases, hospitalization, deaths) among historically marginalized and disadvantaged racial and ethnic populations and other underserved population groups (here defined, consistent with Executive Order 13985, as “populations sharing a particular characteristic, as well as geographic communities, that have been systematically denied a full opportunity to participate in aspects of economic, social, and civic life, as exemplified by the list in the preceding definition of ‘equity’”).^6,7,12,16,17 Information on how STLT professionals continue to advance health equity while facing complex disparities and worsened inequities can illustrate how essential services to optimize and close gaps in population health are sustained or strengthened dynamically.

This supplement to Public Health Reports, organized by the Centers for Disease Control and Prevention’s (CDC’s) Office of Health Equity, provides accessible, useful information from the front lines of public health to inform health equity practice. Four article categories representing distinct practice-based research types are showcased: (1) research addressing questions, problems, and uncertainties identified by public health data and practitioners and emerging in real-world practice; (2) research investigating the implementation and effect of public health strategies in representative communities and practice settings under usual rather than highly controlled conditions; (3) research studying the feasibility, effectiveness, and impact of untested public health innovations developed by practitioners; and (4) studies using data generated by public health practitioners to produce practice-relevant knowledge.

Research Addressing Questions, Problems, and Uncertainties Identified by Public Health Data and Practitioners and Emerging in Real-World Practice

Rhodes et al ¹⁸ attend to the salience of how tribal data are collected, accessed, shared, and used by American Indian and Alaska Native populations. Spurred by the COVID-19 pandemic, STLT, and CDC’s declaration of racism as a public health issue, as well as the Robert Wood Johnson Foundation’s Commission to Transform Public Health Data Systems to improve health equity data, a panel of tribal representatives, academicians, public health practitioners, and federal employees convened to inform the Commission’s recommendations. Examples of key components included elevating and recognizing tribal sovereignty and restoring cultural data practices.

Tribal access to data is supported by Executive Order 13175, signed by President Biden in 2021. ¹⁹ Furthermore, integration of tribal health equity and well-being requires collaboration and consultation with tribes to understand what knowledge, data and analytic methods, and surveillance systems are needed to address the health and healing needs of their communities. Traditional values and practices, such as the Medicine Wheel ²⁰ and Becoming Butterfly ²¹ frameworks, are discussed as models that American Indian and Alaska Native public health professionals are using to determine metrics to advance health equity. The authors note that tribal ways have systematically been overlooked, downplayed, and misrepresented across many sectors, including public health. This article also informs the broader health community on why embedding cultural norms is critical to eliminating stereotypes, improving data accuracy and conceptualization, and reporting findings for policy promotion and resource allocation. Recommendations for public health professionals in American Indian and Alaska Native health systems outline tenets that should be standard practice.

Meehan et al ²² investigate gaps in COVID-19 pandemic surveillance data among people who have disabilities, who are unhoused, and who have substance use disorders. The pandemic signaled how the lack of sufficient data systems and health infrastructures perpetuate health inequities and stymie appropriate responses in populations at greatest risk for SARS-CoV-2 virus infection. In conjunction with the Health Federally Funded Research and Development Center, operated by the MITRE Corporation and CDC, rapid qualitative interviews were conducted with selected jurisdictions and interviewees from public health, hospitals, community organizations, and patients. The interviews revealed key challenges in how data elements fail to capture sufficient evidence for the 3 populations traditionally underrepresented by surveillance systems. Their findings uncovered deficiencies in data definitions; identified resources to create and maintain up-to-date, interoperable data structures; and provided justifications for the data, including ethical use and privacy concerns.

A seminal challenge for public health and health care is devising solutions to build strategic, long-term capacity to manage data structures. Jurisdictions must collaborate with relevant federal, state, and local public health agencies to resource and advocate for meaningful, usable data that improve health equity for the most vulnerable and voiceless groups. Expanding the sample of jurisdictions may offer additional insights into data collection and surveillance needs for people who have disabilities, are experiencing homelessness, and have substance use disorders.

Research Investigating the Implementation and Effect of Public Health Strategies in Representative Communities and Practice Settings Under Usual Rather Than Highly Controlled Conditions

Outreach efforts were vital in reaching racially and ethnically minoritized, underrepresented communities during the COVID-19 pandemic. Like many US jurisdictions, Houston, Texas, experienced higher rates of unvaccinated and vaccine-hesitant individuals and deaths from COVID-19 among Hispanic and Black residents than among White residents. Using census-tract data and spatial analytics to identify affected communities, Munoz-Lavanderos et al ²³ conducted and evaluated tailored events in 2 Hispanic communities and 1 African American community. Two frameworks, the Precede–Proceed model and RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance), guided the study. Program implementation involved focus groups with community interest holders and deployed community health workers (CHWs). CHWs, local public health officials, community-based organizations, and academic partners composed an advisory board to identify metrics for success. Improved vaccine education and rates of vaccination were seen across all sites, although not equally; integrating follow-up with participants could provide additional insights on vaccine uptake. Satisfaction with the outreach efforts was observed, with convenience and participant incentives rated most favorably.

Each Houston community required a tailored approach to reaching its intended beneficiaries. The article by Munoz-Lavanderos et al illuminates the benefits of tailoring strategies to promote COVID-19 vaccine education and uptake and further highlights the need for academic and public health practitioners to engage with community members throughout all program implementation phases. A paramount insight from the COVID-19 pandemic is that undervaluing authentic community engagement will hinder trust and engender misinformation and vaccine hesitancy, stalling the advancement of health equity among historically marginalized and disadvantaged racial and ethnic populations. The 30-year literature on community-based participatory research has documented the salience of community partnership in health. ²⁴

The COVID-19 pandemic highlighted gaps in funding, staffing, and political support across public health agencies. Pima County, Arizona, was hit hard by COVID-19, experiencing very high morbidity and mortality rates from the virus linked to inequities in structural determinants of health and SDoH. In response, the Pima County Health Department (PCHD) initiated a multilevel intervention addressing the health and social inequities of a rural, urban, and mixed population. ²⁵ This case study, by Monroy et al, describes the deliberate strategies undertaken, first undergirded by Pima County’s resolution codifying racism as a public health crisis. Three key strategies were implemented in the PCHD intervention: (1) establishing government relations and buy-in, (2) incorporating internal administrative policies and procedures, and (3) activating community engagement and voice.

In using local, state, and national data and proxy measures from the Social Vulnerability Index and the COVID-19 Community Vulnerability Index, PCHD and community interest holders were intentional in their shared efforts to adequately mitigate and plan for current and future public health threats. This case study also focuses a wide lens on the need for public health agencies and interest holders to nimbly pivot and adapt to persistent and emerging health disparities and health inequities. ²⁵ A clarion call from the authors to public health is the critical need for supportive government, appropriate funding to sustain a well-trained workforce, and commitments to address equity and associated health outcomes.

Research Studying the Feasibility, Effectiveness, and Effect of Untested Public Health Innovations Developed by Practitioners

Articles in this section examined interventions ranging from training to reduce racial implicit bias among maternal health care professionals to Medicaid’s effectiveness in reducing poverty’s constraint of access to health services among adults with asthma. Mishkin and Flax ²⁶ posit that serving racially and ethnically diverse populations requires examining each professional’s role in health care encounters. How each professional engages patients and their families in maternal health care settings affects health care use behaviors, is linked to trust in health care institutions, and is tied to disparities in maternal health care outcomes among racially and ethnically minoritized populations.^27-30 Reducing implicit bias as an element of the praxis of professionals delivering maternal health care is essential to ensuring that race and ethnicity are not drivers of care outcome disparities. Increased and sustained institutional attention to eliminating implicit bias–driven behaviors and facilitators in maternal health care is critical to ensure all mothers and infants have fair and just opportunities to attain their highest level of health. This continued emphasis is urgent given that the maternal mortality rate increased significantly from 2019 to 2021; 2021 rates among Black women were significantly higher than among White and Hispanic women, and significant increases were reported for all racial and Hispanic-origin groups. ³¹ It is also crucial given connections of high maternal mortality to racial inequities, low numbers of hospitals providing maternity care, and workforce shortages for health care positions, such as nursing.^31-33

Articles by Harmon et al, ³⁴ Nawaz et al, ³⁵ and Bakshi et al ³⁶ share a primary emphasis on expanding access to health protective resources. In rural Alaska homes lacking access to piped water, installing in-home handwashing stations expanded access to clean water as a condition vital for health, the importance of which increased when basic hygiene practices, such as handwashing, were recommended to reduce the spread of COVID-19. ³⁴ Adherence to COVID-19 recommendations was facilitated by strategic public–private partnerships promoting the use of low-cost, innovative Mini Portable Alternative Sanitation Systems. This promising multiagency partnership demonstrates how to leverage diverse resources and systems-change openings (ie, opportunities for change that could alter systems in ways that would expand access to conditions vital for health and well-being) accompanying public health emergencies to address enduring inequities.

Both the ¡Ándale! ¿Qué Esperas? campaign ³⁵ and the BREATHE pilot program ³⁶ overcame the COVID-19 pandemic and its exacerbated service challenges by “meeting people where they are.” They established the utility of virtual engagement approaches, respectively, among Latinx/Hispanic communities disproportionately affected by COVID-19 in California and Black and low-income families disproportionately affected by asthma in Louisiana. During the pandemic, multicomponent outreach efforts, including virtual outreach, removed structural, behavioral, and sociocognitive barriers to disease prevention and control. These efforts made COVID-19 vaccination more acceptable, expedited performance of recommended actions (eg, removal of environmental asthma triggers), and achieved progress toward health improvement objectives (eg, improved asthma symptom control). Achievements noted for the ¡Ándale! ¿Qué Esperas? campaign are also likely the result of efforts of CHWs collaboratively deployed by 5 centers serving various California counties. Despite the pandemic’s constraints on in-person contacts, these professionals repackaged highly specialized information to be more easily understood, provided structurally and culturally competent outreach, and ensured that more Latinx communities used vaccines. Despite resource limitations, the centers jointly increased access to connectors who were one with the served communities.

Findings reported by Qin et al ³⁷ encourage continued attention to interrelationships among the many factors affecting health care use in adults with asthma and low incomes. Being able to access Medicaid may expand options for managing asthma but may not elicit participation in routine medical visits or the use of asthma controller medications. Examining barriers to asthma-related health care use beyond health care costs may be beneficial to the development of comprehensive strategies for advancing health equity. Such nonfinancial barriers might include transportation challenges, work or other conflicting commitments limiting participation in appointments, competing family care needs, health care provider supply limitations, and greater difficulties obtaining appointments among Medicaid versus privately insured patients.^38-40 These examinations are essential because addressing common nonfinancial barriers that coexist with problems affording care might advance investments in improving care affordability into true gains toward access and health equity. ³⁹

Studies Using Data Generated by Public Health Practitioners to Produce Practice-Relevant Knowledge

Winston et al ⁴¹ take a proactive stance through their study, illustrating how to advance health equity through evidence-based practice within overdose prevention and surveillance. This groundbreaking work provides valuable insights into the current state of health equity initiatives based on CDC Overdose Data to Action (OD2A) from 66 OD2A-funded jurisdictions. The study uses the practice-based research approach by generating mixed-methods data through public health agencies and using thematic analysis of qualitative data and descriptive quantitative analyses. It underscores the importance of addressing health inequity via upstream factors, the structural determinants of health, and SDoH, as root causes of overdoses. Moreover, the authors identify several challenges to ensuring health equity, such as gaps in workforce capacity, data access, and data collection on equity assessment. They underscore the importance of subsuming health equity principles into population prevention initiatives. This study is a trailblazer for future efforts not only in drug overdose prevention but also in other public health topics of concern in US communities.

A consensus has evolved in recent decades that simply assessing health disparities is inadequate to effectively address underlying issues facing public health professionals. ⁴² Instead, because health disparities are downstream outcomes of upstream inequities, addressing upstream structural determinants of health and SDoH is essential. Although Ashenafi et al ⁴³ do not mention health equity approaches in their title, they advocate strategic reduction in disparities in COVID-19 immunization uptake through health equity principles, such as those described by Burton et al. ⁴⁴ Their study demonstrates the essential components of applying equity principles of interest holder analysis, engagement, and collaboration when designing federal programs to reduce disparities in adult COVID-19 immunization uptake. The case study shows that to achieve health equity, interventions should empower people through progress in equitable access to SDoH. Culturally sensitive approaches addressing people’s lack of confidence in science and vaccines are critical to tackling vaccine hesitancy. The study yields insights and implications for effective public health practice, suggesting that public health agencies will need to invest time and resources to both build trust and train trusted community members.

Data from accredited health departments, synthesized by Lang et al, ⁴⁵ embody essential elements of practice-based knowledge. These data demonstrate the high level of health departments’ engagement in health equity activities, particularly concerning community partnerships and COVID-19 vaccine provision to disenfranchised populations. Health equity in the United States became a more critical issue during the COVID-19 pandemic because it magnified historical disadvantages among populations typically at a higher risk of poor health outcomes due to social, cultural, and structural barriers to scientific information, adequate housing, wraparound services (support services for individuals receiving medical or public health services) for those affected, and preventive care.^10,46 The study provides examples of best practices for health departments from their peers’ health equity activities. The results show that accreditation of public health agencies plays a central role in mobilizing state and local health departments to support a culture of health equity. Supporting with examples, the study provides paths to systematically embed equity principles in various aspects of public health agencies’ work. The areas of public health practice showcased for using health equity approaches included strategic planning, internal training, data, funding, and community education/training. The study is highly relevant to the theme of this special issue for its potential to promote Health in All Policies and equip the public health workforce with practice-based knowledge for better dealing with hardships from public health crises such as the COVID-19 pandemic, which also affected public health employees severely and inequitably.^15,47

The case study from King County, Washington, by Wysen et al ⁴⁸ argues for accountability, transparency, and a trust-centric approach when working with racial and ethnic minority groups in the United States, specifically American Indian or Alaska Native, Asian, Black, Native Hawaiian or Pacific Islander, and Hispanic people, amid an ongoing pandemic and systemic racism. It offers a model to proactively understand and remedy sociopolitical injustices concerning structural determinants of health and SDoH and consequent health inequities. The authors outline the antiracist framework devised by the King County Pandemic and Racism Community Advisory Group (PARCAG) for empowering public health agencies to approach structural racism and health inequities through transparency and feedback from those affected. The work of Public Health–Seattle & King County on COVID-19 and antiracism benefited from the PARCAG recommendations. The proposed approach builds on antiracist values, knowledge, strategies, priorities, and experiences of disadvantaged racial groups. Values include responsiveness to the disenfranchised, adaptability, transparency, accountability, empathy, and resolve to eliminate the root causes of health inequities. Public health practice, policy, and initiatives could consider adopting this study’s insights, framework, and recommendations to facilitate the systemic reversal of racial and health inequities.

Conclusions

Assuring substantial improvements in health equity is a complex task requiring dedicated, multisectoral collaborations across all structural determinants of health and SDoH. ⁴⁹ Systematic approaches and actions are necessary to integrate health equity into practice, expand equity-focused technical assistance opportunities, enhance public health capacity through cross-jurisdictional resource sharing, and amplify the voices of those most affected by historic sociopolitical injustices. Health equity efforts are likely more successful if they encompass accountability and methodical, strategic, transparent involvement of leaders in public health and racially or ethnically minoritized communities.

Each of the 4 sections of this commentary aligns with principles of health equity science for public health action outlined by Burton et al. ⁴⁴ Work in section 1 is consistent with the principle of health equity science for public health action urging promotion of the visibility of groups that might be inadequately represented. The efforts that we have briefly characterized model meaningful, comprehensive community–public health practitioner collaboration to identify and overcome access barriers originating from marginalization—illustrating that equity can be secured by building a culture of action addressing structural determinants and root causes of inequity, such as structural racism. Lastly, the endeavors that this supplement showcases directly deploy practice-based research examining associations and interventions in real-world settings replete with their attendant implementation facilitators and barriers. Many of the reported efforts may enhance scientific validity and credibility and promote fairness and initiative ownership. The findings shared may also support ongoing redesign and restructuring of public health data systems, policies, and programs to ensure opportunities for all to thrive.

Articles in this supplement demonstrate key elements of public health leadership and systems, such as flexibility, resourcefulness, and focus, despite the presence of crises and within environments not always receptive of or conducive to public health efforts. The conversation continues about how the pandemic undermined some elements of public health and revealed weaknesses and needs in public health systems and the public health field. This conversation should now be expanded to highlight how public health professionals endured the demanding work amid challenges. Those whose efforts appear in this supplement of Public Health Reports did all of this and generated practice-based research, which shows that research and practice can occur in concert, even during crises, when the right mix of motivations, resources, and support are present. These efforts are a tiny fraction of efforts that are occurring and that we hope will not only continue but also increase. We acknowledge our focus on domestic county, tribal, state, or federal operations but suggest that future work could highlight health equity–centered practice-based research taking place in US territories and freely associated states and globally.