The historic roots of public health practice are grounded in a dual attention to improving the health status of individuals while also reducing risks within the social environment that contribute to poor health outcomes.1–3 1–3 1–3 In 1920, C.-E. A. Winslow described public health as:
The science and art of preventing disease, prolonging life, and promoting physical and mental health through organized community efforts for the sanitation of the environment, the control of community infections ... and the development of the social machinery which will ensure for every individual in the community a standard of living adequate for the maintenance of health.4 (p30)
Improving health and reducing risks also involve the integration of health equity considerations in the design, implementation, and evaluation of prevention programs and interventions.
This article outlines some key elements of what we are terming “health equity programs”—public health programs that are particularly well-positioned to advance health equity. These elements are illustrated with examples of current public health interventions supported by the Centers for Disease Control and Prevention (CDC) that reduce health disparities and show potential to advance health equity. For purposes of this discussion, we define a public health program as a set of complementary strategies, interventions, and activities directed toward furthering 1 or more health goals.
What Is Health Equity?
Over nearly a century since Winslow's characterization of public health practice, the field has emerged as increasingly more specialized, and its practice informed by multiple disciplinary and interdisciplinary perspectives.5–8 5–8 5–8 5–8 Nevertheless, there are still challenges to achieving his depiction of public health. Among these are the concerns of health equity, defined by the US Department of Health and Human Services as “attainment of the highest level of health for all people. 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 health care disparities.”9
Other definitions are also of interest—health disparities and the social determinants of health. Health disparities are differences in health outcomes and their determinants between segments of the population, as defined by social, demographic, environmental, and geographic attributes.10 There are several types of determinants of health including genetic, behavioral, social, and environmental factors.11 Social determinants of health are 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.12 US scholars, including Braveman and Gruskin, have defined health equity as “the absence of systematic disparities in health (or in the major social determinants of health) between social groups who have different levels of underlying social advantage/disadvantage—that is, different positions in a social hierarchy.”13 (pp254,255) Margaret Whitehead, a pioneer in the articulation of health equity, stated, “Ideally everyone should have a fair opportunity to attain their full health potential and, more pragmatically, that no one should be disadvantaged from achieving this potential, if it can be avoided.”14 (p220) Taken together, if reducing (preventable) health disparities is the problem and achieving health equity is the public health goal we are working toward, then addressing the social determinants of health—including ensuring access to high-quality health care—is necessary if we are to attain the highest level of health for all people.
What Programmatic Elements Address Health Equity?
Designing, implementing, and evaluating public health programs to promote health equity are a complex and evolving endeavor. Among the resources that support health and health equity are
opportunities for employment and education, access to transportation, safe and affordable housing, retail outlets including those that sell affordable and quality healthy foods, availability of recreation facilities and health services, limited exposure to environmental hazards, strong social networks and social cohesion, and cultural norms and values that support a healthy lifestyle.15 (p52)
Ensuring access to many of these resources that promote health equity within communities is traditionally outside of the scope of public health practice, but there are coordinating and supportive actions that governmental departments of public health can take to facilitate greater access to these resources in communities at highest risk for poor health.15 , 16 We begin by describing intervention programs designed specifically to reduce health disparities and, toward that end, address 1 or more social determinants of health that enhance health equity.
On the basis of the experiences of selected CDC programs targeting racial and ethnic health disparities in communities that are socially and economically disadvantaged, and often medically underserved, there appear to be several elements in public health program design that enhance health equity. Such a design:
- Considers sociodemographic characteristics such as gender, race/ethnicity, age and language, as well as intersections among these characteristics.
- Takes full advantage of and contributes to the evidence base of interventions demonstrated to have an impact on eliminating or reducing health disparities.
- Leverages effective multisectoral collaboration to create complementary strategies.
- Supports clustering of related interventions to improve health.
- Engenders meaningful community participation by mobilizing community engagement and support.
- Ensures rigorous planning and evaluation, and monitors intended and unintended consequences of programs across different populations and communities.
Our collective experience suggests that any health equity program should consider including all of these elements. A full description of the CDC programs discussed here is beyond the scope of this article, but we highlight aspects of the programs that share 1 or more of the aforementioned design elements in public health practice.
Considers sociodemographic characteristics
Sociodemographic characteristics such as gender, race/ethnicity, age, and language, and the intersections between these characteristics and health disparities, are critical factors to consider in the design of a program or an intervention. The following example illustrates how an intervention for women at high risk for human immunodeficiency virus (HIV) infection considered multiple sociodemographic characteristics in its design.
Healthy Love is an interactive, educational workshop to reduce risk behaviors related to HIV infection and sexually transmitted diseases among heterosexual black women.17 A randomized controlled trial of the workshop was conducted, using comparison groups of women who received only didactic presentations, from March 2006 to June 2007, in the metropolitan Atlanta area. (During a similar time period, 2005-2008, black women accounted for 71% of HIV diagnoses among all women in the Southeastern United States.18) Women were eligible for the evaluation if they were English-speaking African American, African, or Caribbean women, older than 18 years, and not pregnant or planning to become pregnant during the next 6 months.
Healthy Love addresses modes of HIV transmission and strategies for reducing infection risk. A trained facilitator works with small groups of women to provide information on HIV/AIDS and sexually transmitted disease infection and to support skills-building activities and role-play on assessing personal risk, correct use of condoms, HIV testing, and negotiating condom use with male partners. This intervention was designed to address the “shared cultural aspects of black women's experiences that can affect their vulnerability to HIV infection.”17 (p16) For example, one activity is used to show the participants how words describing sexual acts and sexual organs can be used to demean women or reinforce their appreciation of their rights as women relative to their male partners. The black female facilitators were trained in 2-day workshops on the topics included in the Healthy Love curriculum and on the development and implementation of the Healthy Love workshop. The trial results showed that at 3- and 6-month follow-ups, Healthy Love participants reported significantly higher rates of condom use than their comparison participants at last vaginal, anal, or oral sex with any male. Also at 6-month follow-up, Healthy Love participants reported significantly higher rates of HIV testing and receipt of test results. For additional information about the content of the Healthy Love program, see Painter et al.17
Consideration of the socioeconomic characteristics of a target population also applies when prevention interventions are replicated in new settings. The widespread dissemination and replication of evidence-based prevention interventions are standard elements of an effective public health strategy. The literature amply describes the need to use a comprehensive combination of universal and targeted interventions; multilevel interventions; and ecological strategies that address underlying systems, pathways, and contextual forces to reduce health disparities and pursue health equity.19 But even well-researched and replicated interventions require reevaluation, or tailoring, when applied in a new population context, a point that may be neglected in practice.
Considers evidence base for reducing health disparities
The evidence base is growing, but there are still limitations in our understanding of the most effective interventions to reduce health disparities.20 Studies of program interventions that impact “upstream” phenomena may not assess health outcomes directly. Public health programs then must conduct evaluations independently that document and validate the connections between outcomes available in those studies and health outcomes. For example, educational interventions could benefit from further examination of their effects on health disparities.21 Since the late 1990s, the US Department of Health and Human Services has sponsored the Community Preventive Services Task Force's work on the Guide to Community Preventive Services (the Community Guide).22 While the Task Force is an independent panel of health experts, the CDC provides administrative, research, and technical support for Task Force activities. The Community Guide includes systematic reviews and evidence-based findings, as well as recommendations on public health interventions to promote public health in a wide range of public health areas including immunizations, motor vehicle safety, tobacco control, control of excessive alcohol consumption, and juvenile violence, among others.23–28 23–28 23–28 23–28 23–28 23–28 This Guide is used by legislators and public health practitioners in developing and implementing public health policies.
In 2009, the Community Guide launched a series of reviews of interventions focused on social determinants that support health equity, targeting low-income and racial and ethnic minority populations in the United States. The initial focus of the reviews has been education, because of its potential to provide entire cohorts of children and youth with the capacities that enable them to negotiate the world and have productive and healthy lives. Thus far, the Task Force has identified several education interventions that show evidence in improving educational outcomes associated with long-term health, as well as improving social- and health-related outcomes. These include center-based childhood education, full-day kindergarten programs, high school completion programs, and some out-of-school–based education programs.29
Leverages multisectoral collaboration
Positively affecting 1 or more social determinants of health generally requires the participation of multiple sectors within a community to produce complementary sets of strategies, activities, and interventions, including strategies for monitoring social determinants of health with nonhealth data. As an example of multisectoral collaboration, the CDC funded 4 American Indian/Alaska Native tribes during 2004-2009 to tailor, implement, and evaluate evidence-based interventions to reduce motor vehicle–related injury and death in their communities. The communities determined which interventions they would employ and designed multisectoral approaches such as combining safety education programs in schools and communities, media campaigns, and program collaborations with law enforcement. Program outcomes were assessed by using law enforcement data and observational surveys. The results “included increased use of seat belts and child safety seats, increased enforcement of alcohol-impaired driving laws, and decreased motor vehicle crashes involving injuries or deaths.”30 (p28)
Supports clustering of interventions
Clustered interventions may lead to greater impact across multiple public health outcomes, with shared risk factors and social determinants. Frieden has defined an “evidence-based technical package” as “a selected group of related interventions that, together, will achieve and sustain substantial and sometimes synergistic improvements in a specific risk factor or disease outcome.”31 (p17) While Frieden31 was not specifically referring to health disparities, combining related interventions to address health disparities and advance health equity is also a promising strategy. Furthermore, there is support in the literature for combining universal and targeted interventions.31 Strategies can be adapted at multiple intervals, with data collected and analyzed throughout the process to identify effective combinations of interventions. One issue to consider is the “inverse care law,” in which universal health care interventions (in the absence of other supporting interventions) may divert resources from other health care priorities and disproportionately advantage populations with greater resources.32
Community engagement is a concept that has been variously defined and reflects degrees of community or client population power in relationship to external sponsoring institutions, as illustrated in Arnstein's33 Ladder of Participation, which characterizes multiple levels of community engagement. At the lower levels, the engagement is often little more than information sharing and recruitment: situations where interventions are done to communities or for communities. At the higher levels, communities work with institutions to implement interventions and ultimately have decision-making authority regarding intervention design, execution, and evaluation. The CDC Syphilis Elimination Program has noted that community engagement is achieved when affected parties work together “to determine health goals, implement interventions, and evaluate outcomes.”34 (p24)
Communities and populations most at risk for experiencing health disparities are frequently socially marginalized and underserved.35 , 36 They may be distrustful of governmental institutions. Moreover, public health professionals may be reluctant to share decision making with communities when such decisions affect the allocation of scarce resources.37 Under these circumstances, partnerships can take significant time to evolve to a level of cooperation and trust sufficient to be effective as a means of improving community health and health equity. Therefore, a commitment to community engagement usually requires a formative period during which the parties build relationships needed to move the program forward.
The CDC has emphasized the importance of community engagement methods to address health disparities. For example, in the 1999 and updated 2006 National Plan to Eliminate Syphilis from the United States, the CDC requested state and local health departments to directly engage with affected communities to develop and implement comprehensive interventions to reduce the spread of the disease and promote community health.34 As another example, the CDC launched the Tuskegee University Apology Commemoration Activities project.38 This program not only honors the legacy of the survivors of the USPHS Syphilis Study at Tuskegee, and their families, but also enhances the public health workforce by supporting academic and community education and training in bioethics, health care ethics, and public health ethics. Employing a collaborative partnership structure that facilitates shared power and responsibility, the CDC, Tuskegee University, and the community work together to design, implement, and evaluate the project.
Ensures planning and evaluation
Public health programs can benefit greatly from a defined approach to ensure achievement of results, including a rigorous evaluation plan. This approach includes defining the public health problem the program intends to address, changes needed to address the problem (including identification of specific target populations or organizations), and identification of key activities to achieve outcomes.39 For health equity programs, problem definition includes asking what are the disparities, which of these appear to be most inequitable (ie, avoidable and unfair12 , 13), and what are the underlying causes.
When organizations address daunting problems with limited resources, the urgency of the situation can mitigate against dedicating resources to monitoring and evaluation of program effectiveness, since these evaluations can be expensive and time-consuming. Nevertheless, for the field to move forward, it is important to identify which programs are most effective, under what conditions, and what can be done to accelerate the diffusion of the best evidence-based programs. Toward this end, the CDC has developed and implemented the Framework for Program Evaluation in Public Health to assess program impact across the agency's activities.40 Although the framework does not mention health equity, it is an important tool for ensuring rigorous evaluation of health equity programs.
There are several other efforts in the United States that may prompt more in-depth evaluation of health equity programs. For example, state, tribal, local, and territorial public health departments must complete a community health assessment and a community health improvement plan before applying for accreditation.41 The US Internal Revenue Service requires tax-exempt hospitals to perform community health needs assessments at least every 3 years.42 The US Centers for Medicare & Medicaid Services hospital value-based purchasing program43 and similar private sector efforts may create a new level of interest by hospitals in understanding the social determinants of health as a means to improve the health of the populations they serve.
Building Public Health Program Capacity to Address Health Equity
In this section, we discuss other CDC initiatives that are building public health's capacity to enhance health equity. As in any public health endeavor, ongoing efforts can identify effective programs and moderating conditions under which one program is more effective than another. Once the information is available, public health seeks to accelerate the diffusion of the best evidence-based programs. Toward this ultimate end, the following CDC initiatives are producing promising results by increasing understanding and capacity for more rigorous program monitoring and evaluation: engaging the agency's national centers, institutes, and offices and supporting the dissemination of evidence-based approaches to address health disparities and advance health equity.
The CDC funding opportunity announcement (FOA) process is an example of administrative policy that facilitates the consideration of health equity in program funding. In 2012, the CDC established an initiative to strengthen the effectiveness and efficiency of its extramural grant programs by ensuring that CDC FOAs incorporate program strategies to achieve the greatest health impact.44 For the first time, this initiative established minimum standards for all CDC FOAs. These include developing a logic model, including specific measurable outcomes, using evidence-informed interventions and strategies (or a plan to evaluate formative interventions), clearly defining the target population, and establishing performance metrics and outcome evaluation processes to understand how well the program works. The standards require CDC programs to provide key information regarding how the FOA is intended to address specific health disparities (eg, use data to characterize the health disparities that will be addressed and carefully define the target population(s)). As the evidence for health equity programs grows and is documented in the literature, the CDC will use it to provide additional program guidance through the FOA process that moves public health programs toward practices that advance health equity.
The CDC is pursuing a shared vision for the science and practice of health equity across the agency's national centers, institutes, and offices through a series of annual forums involving CDC leaders, scientists, public health analysts, and practitioners. These forums, known as the State of Health Equity at CDC Forum, have been held since 2012. The forums are organized to address key areas of public health research and practice including data methods and measures; program development, implementation, and evaluation; policy perspectives to support health equity; and organizational infrastructure models to ensure the integration of health equity across CDC research, surveillance, and practice. The 2014 forum was focused on health equity and public health programs. Titled “Toward Achieving Health Equity: Emerging Evidence and Program Practice,” this forum explored strategies and complexities associated with achieving health equity through public health prevention programs.
The CDC Health Disparities and Inequalities Report 2011 was CDC's first consolidated assessment of national health disparities; its contents spanned social determinants of health, environmental hazards, health care access, mortality and morbidity, behavioral risk factors, and preventive health services.45 The report and a subsequent report, published in 2013,46 showed that health has improved for many in recent years, yet disparities persist.
The CDC released its first MMWR Supplement, “Strategies for Reducing Health Disparities—Selected CDC-Sponsored Interventions, United States, 2014,” on April 18, 2014.47 This supplement highlighted interventions that are effective or show promise for decreasing health disparities in childhood immunizations, motor vehicle crashes, HIV infection, and tobacco use. These CDC-sponsored interventions were included in the supplement to demonstrate how CDC programs are responding to health disparities data described in the CDC Health Disparities and Inequalities Report and other surveillance reports and to provide examples of effective interventions.
Attaining the highest level of health for all people is supported by effectively reducing (preventable) health disparities, understanding how to address the social determinants of health—including ensuring access to high-quality health care, and being able to measure the impact of health equity programs. In this article, we describe a set of design elements for health equity programs, that is, to consider sociodemographic characteristics, implement evidence-based interventions for reducing health disparities, leverage multisectoral collaborations to create complementary strategies, cluster and implement related interventions for greater health impact, engage affected communities at multiple levels of decision making, and conduct rigorous planning and evaluation. Our experience suggests that any health equity program should consider including all of these elements that call for innovative models for their integration into public health practice. While challenges remain for health equity in the United States, significant work is underway in public health to strengthen the evidence base that can demonstrate complementary sets of strategies, interventions, and activities that achieve health equity.
1. Hamlin C, Sheard S. Revolutions in public health: 1848, and 1998? BMJ. 1998;317(7158):587–591.
2. Minkler M. Health education, health promotion and the open society: an historical perspective. Health Educ Behav. 1989;16:17–30.
3. Green LW, Allegrante JP. Healthy People
1980-2020: raising the ante decennially or just the name from public health education to health promotion to social determinants? Health Educ Behav. 2011;38(6):558–562.
4. Winslow C. The untilled fields of public health. Science. 1920;51(1306):23–33.
5. Roussos ST, Fawcett SB. A review of collaborative partnerships as a strategy for improving community health. Annu Rev Public Health. 2000;21:369–402.
6. Beaglehole R, Bonita R, Horton R, Adams O, McKee M. Public health in the new era: improving health through collective action. Lancet. 2004;363(9426):2084–2086.
7. Israel BA, Schulz AJ, Parker EA, Becker AB. Review of community-based research: assessing-partnership approaches to improve public health. Annu Rev Public Health. 1998;19:173–202.
8. Frohlich KL, Potvin L. Transcending the known in public health practice: the inequality paradox: the population approach and vulnerable populations. Am J Public Health. 2008;98(2):216–221.
10. Carter-Pokras O, Baquet C. What is a “health disparity?” Public Health Rep. 2002;117:426–434.
11. Institute of Medicine. The Future of the Public's Health. Washington, DC: National Academies Press; 2003.
13. Braveman P, Gruskin S. Defining equity in health. J Epidemiol Community Health. 2003;57(4):254–258.
14. Whitehead M. The concepts and principles of equity in health. Health Promot Int. 1991;6(3):217–228.
15. Liburd L, Giles W, Jack L. Health equity: the cornerstone of a healthy community. Natl Civ Rev. 2013;102(4):52–54.
16. Braveman PA, Kumanyika S, Fielding J, et al. Health disparities and health equity: the issue is justice. Am J Public Health. 2011;101(suppl 1):S149–S155.
17. Painter TM, Herbst JH, Diallo DD, White LD. Community-based program to prevent HIV/STD infection among heterosexual black women. MMWR Morb Mortal Wkly Rep. 2014;63:(suppl 1):15–20.
18. Centers for Disease Control and Prevention. Disparities in diagnoses of HIV infection between blacks/African Americans and other racial/ethnic populations—37 states, 2005-2008. MMWR Morb Mortal Wkly Rep. 2011;60:93–98.
19. Jarris PE, Sellers K. Strategies for public health in a transforming health system. J Public Health Manag Pract. 2013;19(1):93–96.
20. Kohatsu ND, Robinson JG, Torner JC. Evidence-based public health, an evolving concept. Am J Prev Med. 2004;27(5):417–421.
21. Conti G, Heckman J, Urzua S. The education-health gradient. Am Econ Rev. 2010;100(2):234–238.
23. Mercer SL, Banks SM, Verma P, Fisher JS, Corso LC, Carlson V. Guiding the way to public health improvement: exploring the connections between the Community Guide's evidence-based interventions and health department accreditation standards. J Public Health Manag Pract. 2014;20(1):104–110.
24. Groom H, Hopkins DP, Pabst LJ, et al. Immunization information systems to increase vaccination rates: a community guide systematic review. J Public Health Manag Pract. 2015;21(3):227–248.
25. Shults RA, Elder RW, Nichols JL, Sleet DA, Compton R, Chattopadhyay SK. Effectiveness of multicomponent programs with community mobilization for reducing alcohol-impaired driving. Am J Prev Med. 2009;37(4):360–371.
26. Hopkins DP, Briss PA, Ricard CJ, et al. Reviews of evidence regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke. Am J Prev Med. 2001;20(2)(suppl):16–66.
27. Hahn RA, Kuzara JL, Elder R, et al. Effectiveness of policies restricting hours of alcohol sales in preventing excessive alcohol consumption and related harms. Am J Prev Med. 2010;39(6):590–604.
28. Anderson LM, Scrimshaw SC, Fullilove MT, Fielding JE; Task Force on Community Preventive Services. The Community Guide's model for linking the social environment to health. Am J Prev Med. 2003;24(3)(suppl):12–20.
30. West BA, Naumann RB. Tribal motor vehicle injury prevention programs for reducing disparities in motor vehicle–related injuries. MMWR Morb Mortal Wkly Rep. 2014;63(suppl 1):28–33.
31. Frieden TR. Six components necessary for effective public health program implementation. Am J Public Health. 2014;104:17–22.
32. Moore TG. Rethinking Universal and Targeted Services. Parkville, Victoria, Australia: Centre for Community Child Health; 2008. Centre for Community Child Health Working Paper 2.
33. Arnstein SR. A ladder of citizen participation. J Am Inst Plann. 1969;35(4):216–224.
34. Centers for Disease Control and Prevention. The National Plan to Eliminate Syphilis From the United States. Atlanta, GA: US Department of Health and Human Services; 2006:1–56.
35. Robertson A, Minkler M. New health promotion movement: a critical examination. Health Educ Q. 1994;21(3):295–312.
36. Stephens C. Beyond the barricades: social movements as participatory practice in health promotion. J Health Psychol. 2014;19(1):170–175.
37. Valdiserri RO, Aultman TV, Curran JW. Community planning: a national strategy to improve HIV prevention programs. J Community Health. 1995;20(2):87–99.
39. Centers for Disease Control and Prevention. Introduction to Program Evaluation for Public Health Programs: A Self-study Guide. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, Office of the Director, Office of Strategy and Innovation; 2011:1–103.
45. Centers for Disease Control and Prevention. CDC health disparities and inequalities report—United States, 2011. MMWR Surveill Summ. 2011;60(suppl):1–113.
46. Centers for Disease Control and Prevention. CDC health disparities and inequalities report—United States, 2013. MMWR Surveill Summ. 2013;62(suppl 3):1–187.
47. Centers for Disease Control and Prevention. Strategies for reducing health disparities—selected CDC-sponsored interventions, United States, 2014. MMWR Surveill Summ. 2014;63(suppl 1):1–2.