Over the past decade, momentum to address social determinants of health (SDH) and health equity increased. Definitions of health equity are wide ranging.1–41–41–41–4 The US Department of Health and Human Services defines health equity as “attainment of the highest level of health for all people.”5 The definition goes on to add, “Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and healthcare disparities.”5 Achieving health equity then requires addressing SDH, “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”6
Landmark reports and national initiatives3,7 argue for the implementation of research, policies, and frontline practice programs that address SDH to reduce health disparities—differences in health outcomes and their determinants between segments of the population, as defined by social, demographic, environmental, and geographic attributes8—and improve population health. For example, in 2008, the World Health Organization's Commission on the Social Determinants of Health released its report, Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health, sparking renewed action among public health and health care practitioners, policy makers, and other stakeholders to examine “the unequal distribution of health-damaging experiences” and “...the structural determinants and conditions of daily life...” experienced by certain population groups and identify strategies to mitigate the impact of these inequitable conditions on population health.3 Healthy People 2020—the nation's health promotion and disease prevention initiative to improve the health of all people in the United States—added SDH as a topic area for the first time in its 40-year history.6
Similarly, the National Partnership for Action to End Health Disparities—a 2011 US Department of Health and Human Services initiative—framed its approach for achieving health equity with “...factors that may long predate the appearance of disease. Such factors are those that relate to social constructs rather than medical constructs and are fundamentally and particularly toxic to health.... Examples include residence in geographic areas that have poor environmental conditions (eg, violence, poor air quality, and inadequate access to healthy foods), racism, inadequate personal support systems, limited literacy, and limited English proficiency (LEP).”5 Philanthropic organizations, for example, the W.K. Kellogg Foundation9 and the Robert Wood Johnson Foundation,10 national organizations, community-based organizations, and academic institutions alike are also making significant investments that would advance health equity.
The Role of the Environment in Framing Health Equity
“Where you live determines your health” has long been used to underscore “place matters” as an SDH. However, the environment impacts health and influences health equity much beyond geospatial parameters. In its broadest sense, the environment consists of 4 domains: physical, built, social, and policy. The interdependence of these paradigms represents a root cause of health inequity. Silo-based interventions that do not target all of these domains are insufficient to achieve sustained health improvements. While programs have been implemented addressing public health issues within the physical and built domains, most were designed using a “snapshot” as baseline to inform interventions.11,12 Furthermore, solutions to challenges that are social and policy in nature require a comprehensive, transdisciplinary approach.
Analogous to environmental health, addressing health equity in a sustainable fashion requires a life span and population-level approach as depicted in Figure 1.13 The Public Health Exposome model takes into account life span exposure, the interaction between an individual and the environment, and factors influencing population health outcomes.13 Personal attributes, including genetic predisposition, are often incorrectly identified as major contributors to overall health outcomes. Compared with individual risk factors, population-level environmental domains and stressors have a greater impact on overall health outcome.12 More specifically, the root causes for health inequity can be directly linked to a failure to address these population-level parameters, most prominently the moderating factors.
The Conceptual Evolution of Health Equity at the Centers for Disease Control and Prevention and Departments of Public Health
There is broad awareness at the Centers for Disease Control and Prevention (CDC) and its public health practice counterparts that SDH play a key role in shaping risks for poor health outcomes and conversely in protecting people from certain health conditions. Several national centers, institutes, and offices within the CDC have provided leadership in framing and demonstrating how public health programs can advance health equity in concrete and measurable ways. At the same time, there is growing recognition that achieving sustainable public health equity requires a more comprehensive, holistic, and transdisciplinary approach involving a collaborative set of multisectoral stakeholders in the public, private, and not-for-profit sectors.
The Role and Potential of Departments of Public Health in Pursuing Health Equity
Leadership from state and local health departments has played an important role in promoting health equity in the past decade.14 Pursuing health equity through the lens of key elements of established public health practice—data and measurement, program implementation, policy, and organizational infrastructure—is promising. For example, standardizing collection of certain data elements (eg, race and ethnicity, language, and country of origin) at the state and local levels, developing data reports that support decision making on programs and policies, and investing in and implementing integrated data systems that collect data from various health and human service agencies all support achieving health equity.15 Furthermore, as conveners of multisectoral partnerships between communities, states, and national organizations, departments of public health are able to strategically realize a “Health in All Policies” approach.16,17 In addition, state health agencies have used grant making as an effective health equity strategy by requiring applicants to include community-based activities and by strengthening the success rate of minority-led organizations. Many state and territorial health officials are also strengthening their state offices of minority health by elevating the office to the leadership level within the agency and are recalibrating their partnerships with communities to promote policies and systems that improve conditions for their residents.
Moving Health Equity Forward in Public Health
Critical to achieving health equity is addressing the bidirectional linkages among science, policy, and practice.13 As illustrated in Figure 2, science can significantly contribute to health equity if public health research is translated into effective policy and evidence-based practice is aimed at prevention, where possible, and risk reduction as a rule. Effective policy interventions are those applying the most contemporary science including predictive risk modeling.18 In addition, public health policies, even those designed to promote health equity, will only make a difference if implemented as fully intended and enforced consistently. When data guide the assessment of public health program implementation through monitoring and evaluation, effective public health practice can provide services tailored to community assets rather than needs alone, thereby maximizing opportunities to advance health equity.
In collaboration with the Association of State and Territorial Health Officials, this supplement describes an epidemiologic and conceptual framing of the science and practice of health equity with case examples from state departments of public health. The 11 articles in this special issue describe health disparities among racial/ethnic groups and among sexual minorities and present promising strategies and methodologies for pursuing health equity with examples from departments of public health and the CDC. The commentaries represent perspectives from national leaders in health equity. We believe this supplement builds upon experiences in public health to advance health equity and can be a welcome resource for assessing the capacity of state, tribal, local, and territorial departments of public health to pursue health equity initiatives, for training the current and future public health workforce, and informing the planning, implementation, and evaluation of public health strategies that foster optimal health for all.
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2. Braveman P, Gruskin S. Defining equity in health. J Epidemiol Community Health. 2003;57(4):254–258.
3. World Health Organization, Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the commission on social determinants of health. http://www.who.int/social_determinants/thecommission/finalreport/en
. Published 2008. Accessed October 30, 2015.
4. Farrer L, Marinetti C, Cavaco YK, Costongs C. Advocacy for health equity: a synthesis review. Milbank Q. 2015;93(2):392–437.
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11. Cetateanu A, Jones A. Understanding the relationship between food environments, deprivation and childhood overweight and obesity: evidence from a cross sectional England-wide study. Health Place. 2014;27:68–76.
12. Sun-Young K, Sheppard L, Kaufman JD, Bergen S, et al. Individual-level concentrations of fine particulate matter chemical components and subclinical atherosclerosis: a cross-sectional analysis based on 2 advanced exposure prediction models in the multi-ethnic study of atherosclerosis. Am J Epidemiol. 2014;180(7):718–728.
13. Juarez PD, Matthews-Juarez P, Hood DB, et al. The Public Health Exposome: a population-based, exposure science approach to health disparities research. Int J Environ Res Public Health. 2014;11(12):12866–12895.
14. Ehlinger EP. We need a triple aim for health equity. Minn Med. 2015;98(10):28–29.
16. Rudolph L, Caplan J, Ben-Moshe K, Dillon L. Health in All Policies: A Guide for State and Local Governments. Washington, DC/Oakland, CA: American Public Health Association/Public Health Institute; 2013.
17. Tang KC, Ståhl T, Bettcher D, De Leeuw E. The eighth global conference on health promotion: Health in All Policies: from rhetoric to action. Health Promot Int. 2014;29(suppl 1):i1–i8.