What does health equity look like in practice? This post describes the health equity efforts of a small sample of health departments and may serve as a model for other state and local health departments hoping to develop their own health equity plans.

A growing list of institutions has acknowledged health equity as instrumental to public health’s purpose of promoting the health of every person and community^1,2,3. This makes sense given health equity’s origins in social justice and its use as a lens to analyze where society and public health fall short of helping all people^4,5.

Braveman and Gruskin were among the first to discuss health equity through social determinants of health, or the “household living conditions, conditions in communities, and workplaces, and health care”⁵ that depend on one’s power, wealth, social identities (eg, race), and exposure to discrimination or other systemic obstacles. Building on these discussions, Whitehead and Dahlgren went on to definitively define health equity as when, “ideally everyone could attain their full health potential and that no one should be disadvantaged from achieving this potential because of their social position or other socially determined circumstance.”⁶ Most current health equity definitions, including those referenced by Dr. Skky Martin in a previous February blog, follow the lead of Whitehead and Dahlgren^6,7.

As a student reading these authors, I wondered what health equity looks like in practice. I wanted to know what roles health departments, which include state health agencies and local health departments, play in helping everyone live healthy lives to their fullest life expectancy.

As a researcher, I have started to answer these questions by looking at different sources–such as strategic plans, health equity plans, community health improvement or needs assessment plans, and websites– where health departments describe how they intend to promote health equity, racial equity, or anti-racism within their organizations. So far, I have focused on states in the Midwest, but I hope to find sources from all fifty states and Washington, DC, eventually. Nonetheless, this smaller sample reveals some common areas health departments chose to pursue that could be interesting to other health departments thinking of doing the same.

Common Steps Taken by a Sample of Health Departments to Promote Health Equity:

1. Developing shared definitions for values (eg, equity lens, health equity, racial equity, anti-racism, and cultural humility). Allowing staff members and stakeholders to define the values that will set the direction for transforming current and future work increases commitment and reduces ambiguity⁸. Some examples include:
   1. Writing a glossary of important health equity-related terminology for a department to use⁸.
   2. Revising “vision, mission, and values statements” to reflect values that will “foster development of an inclusive and anti-racist culture”⁹.
2. Identifying opportunities for staff members to better practice these values. As staff members gain a deeper understanding of health equity, equity, or anti-racism values and the inequities in the communities they work with, they may become better at identifying barriers preventing health departments from advancing equity¹⁰. Applying equity values every day– from answering phones to creating public health policies–might also help staff members fully internalize these values¹⁰. Here are ways that some health departments foster health equity, equity, or anti-racism approaches in their organizations to increase their staffs’ commitment and capacity to embrace health equity, equity, or anti-racism values:
   1. All staff members undergo trainings on implicit bias, social determinants of health, antiracism, or on Culturally and Linguistically Appropriate Services (CLAS) Standards^{11, 12, 9, 13, 14}.
      1. For example, the City of Milwaukee Health Department advocates that it will continuously improve on trainings based on participants’ evaluations (eg, “pre/post surveys assessing confidence in applying anti-racist practices in daily work, interactions, and communications”^9).
   2. Supervisors and managers will build time for staff members to engage with learning opportunities, meet with staff members on a quarterly basis to discuss how each individual can advance equity, and factor in staff members’ growth in health equity for performance reviews¹⁰.
   3. From day one, new staff members will be exposed to health departments’ equity or anti-racist lens in their on-boarding and staff orientation, which includes an overview of health equity ^8,10.
3. Identifying opportunities to better practice values at the organizational level. Increasing individuals’ knowledge, skills, and confidence will not create sustained change without opportunities to apply this new knowledge. Some of the most thought-through strategies for altering institutional practices, policies, and culture to create such opportunities include:
   1. Surrounding staff members with daily opportunities to practice anti-racism by having “antiracist practices, policies, and learning opportunities integrated into team-building exercises, slides, [and] posters/placards”⁹.
   2. Eliminating bias in how work is being carried out. Saint Paul-Ramsey County Public Health aims to train all staff members on “how to review and examine existing and proposed new policies/procedures in order to expose any bias, inconsistent application, or unintended harm that [they] may cause” with “a racial equity lens.”¹⁵ One area to apply this lens is funding, where Saint Paul-Ramsey County Public Health seeks to apply a racial health equity lens to “100% of public health division budgets” and “98% of […] 2-year budget reviews.”¹⁵
   3. Evaluation as a popular way to prioritize populations with the highest needs into ongoing work. An example is the City of Milwaukee Health Department which aims to increase the number of projects and programs that report disaggregated data and show “performance and anti-racism impact”⁹ to determine where future revenues and resources should be allocated.
   4. Collecting population-level data to monitor ongoing and emerging health disparities at large. This data can help health departments understand its collective impact on communities and identify emerging disparities.
      1. Some public health departments focus on creating better categories (eg, “granular ethnicity, language and birthplace data” or gather data on social determinants of health, like occupation) that align with health disparities so that more accurate data can be collected^{16, 17}.
      2. Cuyahoga County Board of Health¹⁴ is setting up a geographic information system (GIS) to map health disparities data onto specific locations.
      3. Other health departments want to increase involvement of communities most impacted by disparities in data analysis and recommendations, such as collaborating with communities with higher risk for COVID-19 in identifying health interventions¹⁸. Multiple health departments value and seek to increase qualitative data or “incorporating community perspectives, wisdom, and stories” ^{19, 16}. Qualitative data can bring in details or context that might be missed from analyzing quantitative data alone.
4. Retaining staff members from diverse backgrounds and lived experiences. For the moment, this category is less fleshed out. It can be roughly divided into two: 1) long-standing recommendations to diversify health departments; and 2) a newer set of strategies focused on emotional wellbeing and safety.
   1. For the first group, Saint Paul-Ramsey County Public Health¹⁵ set a numeric goal to increase the number of racialized staff members²⁰ and managers (ie, “32 percent of full-time public health staff and managers who identify as American Indian, African American, or people of color ≥ percent of community in their respective cultural groups”). The City of Milwaukee Health Department aims to increase the number of racialized staff members in leadership by establishing “strategies, funds, and programs” to increase their participation in “leadership development opportunities.”⁹ Both recommendations align with common findings from the diversity, equity, and inclusion literature.
   2. Another set of strategies focuses on the stress and safety of staff members, who are underrepresented in the workplace. The City of Milwaukee Health Department sets a goal to “understand the sources of chronic and acute stress–including, but not limited to, stressors caused or exacerbated by racism–in the workplace, and develop strategies to mitigate select stressors.”⁹ It strives to “establish consistent venues, methods, or events to support personal and interpersonal psychosocial healing from community traumas” and with methods “grounded in cultural humility, health equity and anti-racist practices”⁹. Other health departments are exploring options to create staff support groups, such as affinity groups formed for people of the same race or other marginalized social identities, as ways to create a “work environment where staff feel safe, supported and free from discrimination”¹⁵.

I value all I have discussed so far, but the last ones resonated the most for me, even though my past workplaces have not been in health departments. I have witnessed as Black leaders– who were soldiering on days after police had killed one of their community members– felt seen when they finally went to a meeting where it was not business as usual, and the facilitator found ways for their tragedy to be acknowledged without putting them on the spot. As a Chinese American woman living with mental illness, I look for workplaces that prioritize staff members from socially marginalized identities by funding and supporting affinity groups. Like many racialized people, my survival mechanism is not always recognizing when people intentionally or inadvertently treat me differently because I am more outspoken than they expect Asian women to be, or they know I have a mental illness. Being unaware of others’ behaviors and perceptions can impact how I am supervised, what type of work I am assigned to, and what future I have there. I cannot express how grateful I have been to others who have faced similar challenges, recognize their experiences in mine, and urge me to address them.

As racialized people and people from marginalized social identities grow more comfortable in sharing, we will see more strategies informed by their lived experiences. These strategies will make it easier for everyone to stay employed (and not just be hired) at health departments. Our presence might help health departments listen to what members of communities most impacted by health disparities have been saying all along as we all collaborate to create new methods that “strengthen communities to create their own healthy futures”¹⁶. It is an exciting time to see how these strategies will complement existing diversity, equity, and inclusion work as we all strive to make healthy and long lives a reality for all.

References

1. Public Health National Center for Innovations. (n.d.). Transforming Public Health through the FPHS.
2. American Public Health Association. (n.d.). Our Mission. 
3. Centers for Disease Control and Prevention. (2023, March). 10 Essential Public Health Services. 
4. Whitehead, M. (1991). The concepts and principles of equity and health. Health promotion international, 6(3),217-228.
5. Braveman, P., & Gruskin, S. (2003). Defining equity in health. Journal of Epidemiology & Community Health, 57(4), 254-258.
6. Whitehead, M. & Dahlgren, G. (2006). Concepts and principles for tackling social inequities in health: Leveling up part 1. Studies on social and economic determinants of population health, No. 2. Copenhagen: World Health Organization.
7. U.S. Department of Health and Human Services. (2022, March). Health Equity and Health Disparities Environmental Scan.
8. Connecticut Department of Public Health. (2015, July). Connecticut Department of Public Health Office of Health Equity Strategic Plan. 
9. City of Milwaukee Health Department. (2022, July). Strategic Plan 2022-2027.
10. Saint Paul-Ramsey County Public Health (n.d.-a). Saint Paul-Ramsey County Public Health Health Equity Plan 2016-2018.
11. Saint Paul-Ramsey County Public Health. (2022, August). Community Health Improvement Plan (CHIP) 2019-2023.
12. Macomb County Health Department. (2018, August). Macomb County Health Department 2018-2023 Strategic Plan.
13. Florida Department of Health in Gadsden County. (2022, July). DOH-Gadsden Health Equity Plan July 2022-June 2025.
14. Cuyahoga County Board of Health. (n.d.). 2016-2020 Strategic Plan.
15. Saint-Paul County Public Health. (n.d.-b). Strategic Plan 2019-2022.
16. Minnesota Department of Health. (2014, February). Advancing Health Equity in Minnesota Report to the Legislature. 
17. County of San Diego Health and Human Services Agency Division of Public Health Services. (n.d.). 2015 Health Equity Plan. 
18. Alaska Division of Public Health Strategic Plan. (n.d.). Alaska Division of Public Health Strategic Plan 2020-2025.
19. The New York State Department of Health. (n.d.). Strategic Plan.
20. Williams, D. T. (2019). A call to focus on racial domination and oppression: A response to “Racial and ethnic inequality in poverty and affluence, 1959–2015.″ Population Research and Policy Review, 38, 655-663.

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