Achieving health equity across all population groups is a goal that will require vision and commitment from all sectors. Elimination of the persistent differences in health status and health care outcomes as a function of race, ethnicity, English language proficiency, and socioeconomic status has been a national priority for federal agencies for more than 2 decades. While significant strides have been made in defining disparities for some groups, much work remains to fully optimize the health of all persons. The elimination of health disparities will require the engagement of the entire spectrum of basic, clinical, health services, epidemiologic, and behavioral research to inform our understanding of the underlying mechanisms that cause disparities and the development of evidence-based interventions to eliminate them. The collection of granular data on individual demographic and social characteristics in all research studies, all health care settings, and all public health data sets is an essential component to achieving health equity; such data collection should include race, ethnicity, language preference, gender identity and sexual orientation, disability status, socioeconomic status, and immigrant status, as well as information on residential characteristics, psychosocial data, and environmental factors. The active cooperation of all sectors that influence health, such as housing, education, urban planning, food suppliers, transportation, and economic development, in a “health in all policies” approach1 will be essential to addressing the social determinants of health that are the “causes of the causes” of disparities.2 Development of a culturally competent and diverse workforce is also critical to the elimination of health and health care disparities.
As the nation's lead public health agency, the Centers for Disease Control and Prevention (CDC) has a central role to play in achieving health equity by eliminating health disparities and allowing every individual to attain his or her full health potential. In 2014, the Health Disparities Subcommittee of the Advisory Committee to the Director of the CDC presented the following recommendations that were subsequently approved by the Advisory Committee to the Director and accepted by the CDC. They may serve as a useful blueprint for state and local health agencies and other organizations that also have an important role to play in achieving health equity.
Recommendation 1: Develop a CDC framework for action to achieve health equity. The framework for action model is commonly used by the agency leadership to organize complex initiatives.3 The framework for action to achieve health equity should articulate a unifying pragmatic approach that would address the indicators, measures, and tools for monitoring trends in health equity, as well as the evidence-based or promising approaches and the essential program components required to address health equity. It would clarify organizational structures within the CDC that facilitate the integration of health equity into programs and research and would promote policies that support reducing health disparities and achieving health equity, such as those referenced in the National Prevention and Health Promotion Strategy4 and the HHS Action Plan to Reduce Racial and Ethnic Health Disparities.5 See the article by Hall et al,6 titled “Policy Approaches to Advancing Health Equity” in this issue for a more detailed description of these documents.
Recommendation 2: Identify and monitor indicators of health equity. The CDC Health Disparities and Inequalities Report is a seminal resource for the nation in monitoring health disparities and inequalities.7 However, several key challenges in monitoring health equity have yet to be addressed. The inadequate numbers of certain highly disadvantaged groups, such as American Indians, in many routine data sources make it difficult to obtain reliable estimates regarding their health needs. For some groups, such as sexual orientation minorities, there is almost a complete absence of data on some groups. As Penman-Aguilar et al8 point out in their excellent article in this issue, “Measurement of Health Disparities, Health Inequities, and Social Determinants of Health to Support the Advancement of Health Equity,” certain practices in the collection and analysis of data support the advancement of health equity whereas other practices may hinder such advancement. Additional data sources should be developed to allow more complete reporting on disparities experienced by racial and ethnic minorities (including subpopulations), those with limited English proficiency, people with disabilities, sexual and gender minorities, people living in rural areas, and other socially disadvantaged population groups. The CDC should report on these indictors as new data become available.
Recommendation 3: Align universal interventions that promote better public health, with more targeted, culturally tailored interventions in communities at highest risk to reduce health disparities and achieve health equity. Interventions designed to improve the health of all populations are not sufficient to reduce the persistent differences in health status and health outcomes that are experienced by some population subgroups. Effective, targeted interventions to reduce health disparities that are tailored, clinically and culturally, for specific populations must be developed, evaluated, and disseminated. The CDC Community Transformation Grants are a model for other CDC programs to use to reduce health disparities using both jurisdiction-wide approaches and targeted, community-based and clinical interventions.9
Recommendation 4: Support the rigorous evaluation of both universal and targeted interventions and, where indicated, the use of culturally appropriate evaluation strategies, to establish best practice approaches to reduce health disparities and achieve health equity. All programs and initiatives designed to improve health should devote resources for rigorous evaluation to determine the health equity impact.10 A standard health impact assessment may be insufficient to identify the differential impact of the program or intervention on those most at risk of poor outcomes.11
Recommendation 5: Build community capacity to implement, evaluate, and sustain programs and policies that promote health equity, especially in communities at highest risk. Building capacity will require the expansion of technical assistance, toolkits, and other technical resources to community stakeholders, as well as an expansion of funding. Priority areas for such capacity building include:how to address the social determinants of health;how to improve health literacy;how to build cultural competence within the public health workforce; andhow to sustain health equity programs when federal funding ends.
Recommendation 6: Support training and professional development of the public health workforce to address health equity. The CDC, through its workforce programs and its work with public health agencies, should play a leadership role in developing a public health workforce with the skills and competencies to effectively promote health equity. The CDC should continue to support pipeline programs and continuing education programs to ensure a diverse workforce prepared to address emerging public health issues including achieving health equity. The diversity of the workforce has implications for both the quality and fairness of the health enterprise. Diverse teams working together outperform homogeneous teams, particularly when teams address complex problems in biomedical and behavioral research, technology, and health.12,13
Implementation of these recommendations would accelerate progress toward the achievement of health equity. The recommendations offer strategies to address the significant conceptual and methodologic challenges involved in eliminating disparities and to promote more thoughtful consideration of the context within which public health practice and policies operate on minority populations. The proposed emphasis on programmatic evaluation and data collection with a deliberative focus on equity holds great promise for developing equitable public health practice across the nation.
1. Rudolph L, Caplan J, Ben-Moshe K, Dillon L. Health in All Policies: Improving Health Through Intersectoral Collaboration. Washington, DC; National Academies Press; 2013.
2. Marmot M, Wilkinson RG, eds. Social Determinants of Health. 2nd ed. Oxford, England: Oxford University Press; 2005.
3. Frieden T. A framework for public health action: the health impact pyramid. Am J Public Health. 2010;100(4):590–595.
6. Hall ME, Graffunder C, Metzier M. Policy approaches to health equity. J Public Health Manag Pract. 2016;22(suppl 1):S50–S59.
7. Centers for Disease Control and Prevention. CDC health disparities and inequalities report—United States, 2013. MMWR Morb Mortal Wkly Rep. 2013;62 (suppl 3):1–187. http://www.cdc.gov/mmwr/pdf/other/su6203.pdf
. Published November 22, 2103. Accessed October 7, 2015.
8. Penman-Aguilar A, Talih M, Huang D, Moonesinghe R, Bouye K, Beckles G. Measurement of health disparities, health inequities, and social determinants of health to support the advancement of health equity. J Public Health Manag Pract. 2016;22(suppl 1):S33–S42.
10. Heller J, Givens ML, Yuen TK, et al. Advancing efforts to achieve health equity: equity metrics for health impact assessment practice. Int J Environ Res Public Health. 2014;11(11):11054–11064.
12. Hong L, Page SE. Groups of diverse problem solvers can outperform groups of high-ability problem solvers. Proc Natl Acad Sci U S A. 2004;101:16385–16389.
13. Satcher D. Embracing culture, enhancing diversity, and strengthening research. Am J Public Health. 2009;99(suppl 1):S4.
Centers for Disease Control and Prevention; health care disparities; health disparities; health equity; health policy