Embedding Health Equity Science at the Core of Public Health Practice

Health equity has increasingly been recognized as a core priority for governmental public health, and is noted as a primary focus in the 10 Essential Public Health Services, revised in 2020.1-3 As we work to embed health equity within public health policies and programs, we must also reassess the science that drives our health equity practice.4 In 2021, the Centers for Disease Control and Prevention (CDC) launched the CORE Health Equity Strategy, which aims to integrate health equity across the agency's approach to science, interventions, partnerships, and its workforce.2,5 The first pillar of the CORE Health Equity Strategy includes a commitment to health equity science, a conceptual framework defined as follows: Health equity science investigates patterns and underlying contributors to health inequities and builds an evidence base that can guide action across the domains of the public health program, surveillance, policy, communication, and scientific inquiry to move toward eliminating, rather than simply documenting, inequities.6 The principles for implementing health equity science6 highlight the importance of differentiating between the markers and drivers of inequity; being intentional and explicit when incorporating race or ethnicity in data analyses; selecting the right measures of disparity; improving the visibility of underrepresented groups in datasets; and contextualizing public health data with information about the positive and negative structural factors that contribute to health outcomes. Most importantly, this framework emphasizes the imperative for health equity science to draw from and generate knowledge that can be used for action—to transform our public health system. While the health equity science framework is relatively new, the core concepts informing it are not. National public health frameworks are increasingly centering health equity, calling for cross-sector collaborations to address the social determinants of health, and underscoring the need for actionable data to guide and evaluate health equity interventions.3,7-9 State and local public health leaders have similarly affirmed the importance of collecting, analyzing, contextualizing, and sharing data to promote health equity.10,11 By leveraging CDC's health equity science framework, health officials can work with communities to accelerate the generation, implementation, and evaluation of evidence-based interventions to improve equitable health outcomes. State and Local Health Equity Priorities and Organizational Structures The 2023 Environmental Scan of Current and Emerging Public Health Priorities, conducted by the Association of State and Territorial Health Officials (ASTHO), identified equity as a top state public health infrastructure and capacity-building priority.12 The ASTHO and the National Association of County and City Health Officials (NACCHO), the national organizations that support state, island area, and local health departments, have established health and racial equity as strategic priorities, reflecting the practice community's commitment in this space.13,14 To advance health equity science, public health leaders must integrate supportive health equity priorities and organizational structures in their organizations. Over a third of local health departments are actively involved in applying Health in All Policies strategies, according to the 2022 NACCHO Profile Survey.15 In the 2022 ASTHO Profile Survey, state and island area health departments reported that engaging partners in health equity solutions and collecting and monitoring data on race, ethnicity, demographics, and disparities were two of their top health equity priorities.16 These priorities align with health equity science implementation considerations voiced by state and local health department staff, as described by Ottewell et al17—signaling an opportunity to galvanize the public health practice community around health equity science implementation. As far as organizational structures, nearly all state and island area health departments now have, or are working to establish a dedicated unit responsible for health equity and a director who leads health equity activities.16 At the local level, a scan of health departments in the 30 largest US cities found that half had positions or divisions dedicated to racial equity.18 In some local and tribal health departments, additional resources may be needed to help establish formal offices of health equity. While embedding equity into organizational infrastructure is helpful, it is also important that these offices be well-integrated across health department programs, to avoid siloing health equity activities within a single office.19 Centering Equity in Public Health Approaches to Data and Evidence Evidence-based public health and the data that drive it are cornerstones for effective public health practice. Health departments, however, have struggled for decades with outdated and siloed data systems, which impede data linkages across public health and other sectors, limit timely access to data, and obscure health disparities. Across all levels of public health, data system improvements are needed to ensure equitable responses to existing disparities and future threats. CDC's Data Modernization Initiative and the Robert Wood Johnson Foundation's blueprint for an equity-centered data system are supporting momentum for the transformation and development of data systems that are designed to advance health equity.9,20 To bolster health equity science within health departments, public health practitioners must have access to—and support the development of—a strong health equity evidence base. Martin et al21 present a scoping review of health equity interventions conducted with involvement of health departments. This comprehensive review represents an important step in mapping the practice-based evidence available to support health equity science implementation across health departments. Ottewell et al17 highlighted specific characteristics of evidence generation that are important for health equity science, including community-based participatory research (CBPR). CBPR provides the opportunity for communities to name and study their self-defined strengths and resiliency factors. It can also support a deeper examination of health disparities, oppression, and power imbalances,22 while giving community members experiencing marginalization the agency to direct action that mitigates health inequities. As public health seeks to center health equity considerations in its scientific practice, building community trust and participation is critical for addressing public health data collection approaches and relationships that may have historically characterized communities using a deficit-only model, or come across as extractive and one-sided. When inviting and integrating people and communities into public health data operations, health departments have an important role in ensuring community members understand and inform what data is being collected, how it will be collected, and the purposes for which it will be used. Should communities understand and agree to data collaborations, a discussion of data ownership and future usage permissions, including an understanding of and respect for indigenous data sovereignty, is key. Sharing data resources back with communities and promoting safe and timely data exchange between state and local health departments are important uses for public health to support during these efforts. Critical Needs for Advancing Health Equity Science at State and Local Levels State, island area, local, and tribal health departments will be critical partners in advancing the health equity science framework. Commitment from health officials will be essential—in continuing to embed health equity priorities within their organization's strategy and plans; supporting innovation, evaluation, and application of evidence-based and evidence-informed health equity programs and policies; advancing the development of a diverse public health workforce that is equipped to contribute to and apply health equity science; and identifying flexible funding opportunities that enable authentic partnership with communities. The ASTHO and the NACCHO aim to assist state, island area, and local health department leadership and their staff in advancing these efforts. Throughout these efforts, we must also foster partnerships with tribal health departments and the organizations that support them. Within health departments, health equity science should be led and supported by a diverse workforce that reflects the communities they serve. Such a workforce can better define and critically analyze the inequities found in data, as well as identify community resilience factors. Leadership support will be integral in building staff capacity to collect and interpret qualitative and quantitative data; use appropriate language and visualizations to describe health inequities; and center systems-level root-cause analysis in practice. As new researchers and practitioners enter the field, education and mentorship to support ongoing engagement with the concepts of oppression, intersectionality, and power imbalances will also be crucial. To deliver robust accounts of health inequities and promote social justice action, funders must partner with public health practitioners and communities to generate opportunities to improve the quality of public health research, evaluation, and science communication. Funders should support studies that address issues affecting the most medically or socially disadvantaged communities; convene grant review committees with diverse backgrounds to reduce biases in selection processes; and create flexible public health funding opportunities that promote community-based, collaborative approaches to research.23,24 A strategic approach to health equity science requires strong forces 'pushing and pulling' knowledge between the academic and practice communities, and a funding infrastructure that supports strong linkages between these fields of work.25 Health equity science principles should be embedded into all aspects of public health research and practice—ranging from community needs assessments, analysis of surveillance data, and program evaluations to randomized intervention trials. The opportunity of health equity science is not in creating a separate or siloed scientific discipline, but rather in embedding health equity science principles across all the science public health conducts. Doing so will be a critical component in transforming our public health system to better deliver on its promise of protecting and promoting health for all.