How to Use This Tool

The last decade has seen an emergence of toolkits, resources, and guides developed to provide public health professionals and practitioners with the knowledge and skills to eliminate health disparities and advance health equity.  These resources have provided the field with helpful tools with which to better understand the conceptual distinction between health disparities and health equity (which is further explained under the section Defining Health Equity), the root causes and historical drivers of health inequity, and the key environmental factors and community conditions that shape health outcomes. This new web-based guide builds upon this foundation by synthesizing the array of resources in the field into a comprehensive framework that embeds equity within institutional transformation. The critical first step to advancing health equity is ensuring that institutional infrastructure and operations — from what language is used, how activities are structured, how programs are funded, and how staff are trained — are internally aligned with equity principles, even before institutions continue the ongoing external work to advance health equity through programs and services. In this regard, we include important strategies for operationalizing equity not always found in other resources, such as strategies for building internal infrastructure, sustainable leadership, effective communication and framing, and using data.

How to Use this Guide

Building a Movement, Transforming Institutions, a web-based-guide, was developed to support both veteran and aspiring health equity leaders seeking to transform public health institutions — from local and state health departments to research centers — and embed health equity into their day-to-day practices to solve systemic challenges in their neighborhoods and regions. The guide will also equip public and nonprofit health leaders with practical step-by-step guidance on how to implement effective practices, build coalitions and partnerships, advance policy change, conduct communications, and develop and use health equity indicators. This guide includes existing tools and resources in the field that offer an equity-centered conceptual framework, common language, guiding principles, as well as examples from leading institutions across the country that are engaged in these efforts.

Strategies to Institutionalize Health Equity: Tools for institutionalizing health equity are organized into eight broad strategies: 1) Defining Health Equity; 2) Building Leadership for Health Equity; 3) Organizational Capacity Building for Health Equity; 4) Leveraging Institutional Capital for Health Equity Sustainability; 5) Coalition Building and Partnerships for Health Equity; 6) Research and Evaluation for Health Equity; 7) Framing and Communications for Health Equity; and 8) Policy Advocacy to Institutionalize Health Equity. 

Each strategy section includes promising strategies to embed equity, a list of relevant online tools and resources, as well as an example of how a specific tool has been used to institutionalize health equity.

•  Embedding Equity in Practice: Promising practices to institutionalize health equity are provided in each strategy section based on a synthesis of frequently utilized approaches, activities, and decision-making processes within public health departments and academic institutions.  These promising practices describe broad ways to embed equity within an organization using a variety of tools.

• Tools and Resource Links: Several tools and resources for institutionalizing health equity are included in each strategy section.  Links to web-based videos, webinars, assessments, papers, handouts, and case studies are provided.
• Examples: Examples for how a specific tool has been used to institutionalize health equity are provided at the end of each strategy section.  The example tool presented is intended to be emblematic of other tools included in the same section.

Identifying Lessons and Overcoming Barriers

The public health field can achieve widespread impact by prioritizing health equity and viewing its work in service of strengthening families and communities. As movements for social justice continue to gain momentum and grow, some public health leaders have expressed a sense of urgency for the field to better understand how inequity plays out locally. They are looking for local and state health departments to adjust their practice in response to these movements and to deepening health inequities and shifting demographics. While the field continues to grapple with what it means to operationalize health equity, there are lessons to be learned from the experience of those leading the movement. The following points represent a set of common factors that leaders identified as the elements that enabled their institutions to implement an equity-focused framework.

• Support bold leadership that prioritizes health equity, sets a new vision, and supports staff in understanding their roles and responsibilities within a new framework. There must be a long-term commitment to addressing health inequities by senior leadership. Leaders must be risk takers willing to think outside the box while also leveraging traditional public health functions such as research, community-centered care, and data surveillance to advance equity.
• Establish partnerships with other sectors, community leaders, and advocates. Build relationships and work together to identify common goals, align strategies, and identify opportunities for future engagement. Develop trust through long -term involvement with community residents, leaders, and stakeholders.
• Use data and evaluation to make a compelling case for a focus on health equity, track progress toward improved health outcomes, and learn from efforts to shift internal practice. Develop tools to monitor and assess the successful integration of equity into external and internal programs, policies, and procedures.
• Leverage limited resources — human and capital — to develop leadership and shift institutional practice. The tools that follow could be a starting point for training and other resources for public health staff to become more conversant with health equity concepts and practices.
• Dedicate resources to develop and implement a health equity strategy, especially funding to train and build the capacity of staff to adopt a new framework, understand their changing role, and equip them with new knowledge and skills.

The move toward health equity has motivated public health leaders to build stronger connections to other agencies in local government. Public health institutions are engaging in a range of activities including convening interagency working groups, influencing General Plans, training staff on institutionalized racism, and developing tools for assessing equity in internal processes. This work is informed by and builds upon the more traditional public health functions such as conducting research and producing population-level data on health outcomes. The following findings are a collective account of how to overcome barriers to take this work to the next level.

1. Invest in professional development to increase knowledge and capacity that reflects the multidisciplinary nature of health equity. Integrating equity into public health institutions calls for relationship building with a broader set of stakeholders with deeper expertise. As public health departments increase their level of engagement with community members, non-health sectors, policymakers, and the public at large, it is important to build the capacity of staff to communicate and collaborate across sectors and issues.
2. Develop a framework and narrative grounded in facts and data, and focused on equitable health outcomes. The intelligent, strategic use of language, data, and story are critical to build the support and partnerships necessary to advance health and equity. Framing issues related to social and economic inequity in public health terms will also clarify the role and responsibility that public health has in advancing equity.
3. Integrate equity broadly into the policies, procedures, and practice of public health institutions. Institutional goals and objectives should aim to advance the principles of equity such as inclusion, community participation, and multisector collaboration. These goals should guide strategy and inform how institutions work with community and other sectors.
4. Commit to community engagement as a core strategy for advancing health equity. Effectively addressing the systemic inequity that leads to persistent disparities in health will require increased partnership with community stakeholders. As the focus of a public health department shifts over time, the institutions can remain responsive to residents' needs by aligning their agenda with those of local partners so that community priorities remain paramount.
5. Prioritize building partnerships beyond the health field. Partnering with other sectors and fields is critical to addressing the systemic inequities that underlie persistent racial and ethnic differences in health. Public health departments should strive to establish partnerships that reflect the complex relationship between health, place, and race.

The Opportunity Ahead

The field of public health has an opportunity to call out racism and embrace justice as both a guiding principle and desired outcome. Racial inequities in education, housing, and employment, while disproportionately impacting communities of color, ultimately harm everyone. Supporting efforts to advance economic justice will be an important dimension of leadership in health equity. Employment has long been a strong predictor of health, and research has shown that economic inequality leads to worse overall health for all Americans. Going back nearly 40 years, we see that people of color have been unemployed at rates significantly higher than Whites while at the same time national income inequality — one measure of economic inequality — has steadily increased However, if the racial gap in income were closed, the national gross domestic product (GDP)would increase by $2.1 trillion. This sizeable increase in productivity would benefit all Americans making racial economic inclusion good for both the national economy as well as the health of communities. 

The work of defining and promulgating "health equity" and painstakingly building stronger institutions is necessary, but public health practitioners must take that up while they address the urgent health needs of their constituents. The activities being undertaken to change harmful policies and deepen relationships with local leaders and stakeholders take on a renewed sense of urgency. The public health community will need to continue fighting for the rights of the uninsured and for programs and policies aimed at addressing racial and ethnic differences in health. However, public health should also see itself as part of a larger movement for racial and economic equity and align itself with social justice advocates. Communities, especially those shouldering the burden of disease and experiencing the deepest inequities, will need a public health profession that brings a sharp analysis of systemic inequity and the skills necessary to ensure benefits to all.

Defining Health Equity

Institutionalizing health equity — within public health institutions, the health sector, and beyond — begins with defining health equity.  Health equity is achieved when everyone, regardless of race, neighborhood, or financial status, has the opportunity to experience the highest level of health.  It includes a broad definition of health as physical, mental, economic, and social well-being, and focuses on the social determinants of health.  Health equity broadens the disparity concept by necessitating a deeper exploration and analysis of the underlying factors that contribute to differences in health outcomes. With a clear, concise definition of health equity, organizations can begin to make critical decisions about the resources and strategies needed to institutionalize health equity.    

Why Health Equity?

"Health equity" provides a new definition of health that is not simply the absence of disease, but rather the overall quality of life. Unlike health disparities, which are simply differences in health outcomes across groups, health equity views poorer health and higher rates of death as the result of avoidable, unjust circumstances.  Health equity requires that we value everyone, equally, with focused and ongoing societal efforts to address avoidable inequalities, redress historical and contemporary injustices, and eliminate health and health-care disparities. Focusing on health equity shifts the questions we ask from, "Who is at more risk for disease?" to "Why are some populations at greater risk of preventable illness than others?" A health equity approach allows us to promote optimal health for everyone by addressing the underlying causes of poor health, prioritizing the needs of marginalized people, and creating conditions that allow everyone to thrive.  Achieving health equity begins with defining and practicing it within our institutions.

Embedding Equity in Practice: Promising Strategies

1. Develop a shared definition of health equity. Because multiple definitions of health equity often exist within the same institution, it is important to develop one shared definition — across departments, functions, and job classifications — that is firmly grounded in the context of race and institutional racism.  Race and racism have fundamentally shaped our economic, social, and physical environments, and are therefore central considerations for achieving health equity. Utilizing existing definitions and frameworks, while engaging the experiential knowledge of staff, can collectively support the creation of a meaningful and shared baseline definition.
2. Identify opportunities to revisit and reiterate the shared definition for understanding. Developing a shared understanding and language about health equity requires more than just a definition.  Strong leadership and frank conversations are needed to ensure that an organization's understanding, and subsequent practice, of health equity is dynamic, iterative, and reflective of the lived experiences of those within the organization and broader community.  Leadership ensures that sufficient resources, time, and priority are given to the process of establishing an understanding of health equity across the organization. Similarly, frank conversations, where staff feel safe and affirmed while sharing authentically, are needed.       
3. Incorporate the definition into your organization's mission, values, strategies, and practices. Once a shared definition and understanding have been established, finding opportunities for diffusion and integration are important.  Institutionalizing health equity, and addressing the root causes of health and racial inequities, can occur when a shared understanding of race, racism, and health equity is reflected and articulated throughout the organization —  from the core mission, to the daily practices, and everything in between. 

The tools included for this section can be downloaded on the resources page.

• Defining health equity
• Understanding the social determinants of health
• Root causes of racial and health inequities

Example: A Tool for Defining Health Equity

PolicyLink, Health Equity: Moving Beyond "Health Disparities" The definitions of health equity and health disparities found in this paper can be used to help your organization create its shared definition of health equity. PolicyLink has used the definition to frame health equity as a civil rights issue: http://plcylk.org/2hfwG8k 

Building Leadership for Health Equity

Taking bold action to move individuals and systems towards health equity practice requires leadership at all levels. High level, formal leadership plays an important role in cultivating the organizational commitment needed to achieve health equity.  It also allows navigation through the various political and institutional contexts surrounding health equity work.  Leadership at all levels is needed to successfully implement the community partnerships, research, communications, and advocacy strategies integral to institutionalizing health equity.  Leaders ensure that the necessary resource and prioritization decisions are made to support change and promote equitable practices, both inside, and outside, of organizations.  Building leadership within communities, with an emphasis on lifting up grassroots leaders, promotes shared agency and equity between public health institutions and the communities they serve. 

Why Leadership Building?

The decision to focus on health equity, and adopt equitable organizational practices, requires a range of resources and capabilities that may not already exist within an organization.  Leadership building demonstrates an organization's commitment to allocate resources towards creating and sustaining the people and practices that promote health equity.  It includes assessing capabilities and developing goals to measure progress.  It requires investments in training, professional development, and power building within the organization, as well as the surrounding local community.  Leadership building ensures that the critical human resources, talent, and skills needed to achieve equity are identified, cultivated, and supported.

Embedding Equity in Practice: Promising Strategies

• Develop a vision, assess competency, and manage leadership development goals at the highest levels of leadership. Commitment and resource allocation are critical to institutionalizing health equity, and require strong leadership at the highest levels of an organization.  Critical and effective leadership decisions are informed by a vision, accurate and reliable data, and clear goals concerning the systemic changes needed to promote health equity within and outside of an organization. 
• Identify opportunities and resources to build leadership across the organization. With strong leadership at the highest levels comes the opportunity to also develop strong leadership across an organization.  The substantive commitment to institutionalize health equity made by senior leadership is complemented and furthered by the daily commitments made by capable leaders across the organization.  Identifying the leadership opportunity for each staff person, and mobilizing the resources needed from them to perform their respective role and responsibilities, is crucial.
• Support/Invest resources towards building leadership from within communities. Concurrent with the internal leadership development investments is the need to also invest in developing community leadership.  Health equity requires that institutions engage in skill-building activities focused on the capacities and visibility of leaders within a community or agency.  Early and intentional planning better anticipates, and responds to, the inevitable leadership and staff transitions, while sustaining efforts.

The tools included for this section can be downloaded on the resources page.

• Personal leadership assessments
• Developing leadership across an organization
• Building community leadership capacity

Example: A Tool for Building Leadership

ASTHO, The Role of the State and Territorial Health Official in Promoting Health Equity
The Association of State and Territorial Health Officers is building leadership, organizational structures, and strategies through its 2016 President's Challenge, Advance Health Equity and Optimal Health for All: http://www.astho.org/Health-Equity/2016-Challenge/

Organizational Capacity Building for Health Equity

In order to initiate and advance health equity, the necessary organizational infrastructure needs to be in place. From developing a shared organizational understanding to adopting a health equity lens, to integrating health equity into an organization's infrastructure — the mission, vision, goals, and program areas — health equity must be incorporated into every facet of an organization. Organizational capacity building requires investments in staff training, learning, and development to build individual capacity. A variety of tools and resources are needed to build organizational capacity for health equity, and to transform internal practice and systems. 

Why Organizational Capacity?

In order for public health departments and academic institutions to achieve health equity, the people and systems within those institutions must have the capacity to address the social determinants of health and racial inequity. Building organizational capacity establishes the structures and capabilities needed to promote health equity, while also monitoring progress. Without organizational capacity, the best plans lack the most critical inputs, and could fall short of the intended goals.   

Embedding Equity in Practice: Promising Strategies

• Concretize organizational commitment by integrating health equity into the core goals, strategic plan, performance plans, and programs. Once an organization has prioritized health equity, the commitment needs to be firmly established.  Incorporating health equity into the guiding principles, organizing documents, and work structure is part of the ongoing capacity-building process.  Updating recruitment practices, building accountabilities into training and development plans, establishing work groups, and integrating health equity into programs and services, help build the infrastructure and capacity needed to advance health equity.
• Perform assessments to identify individual and organizational capacity needs, develop appropriate goals, and monitor progress. Assessing baseline organizational capacity — through staff, leadership, and community partner surveys — provides comprehensive information for setting goals and strategically addressing capacity gaps. Multiple assessment tools have been created, and can be adapted, to measure organizational capacity across several domains, including: institutional commitment; hiring; communication; staff support; institutional support; and data and planning.  
• Align existing and new resources to support capacity-building activities. Financial resources are needed to build the capacity of people and systems to advance health equity. In some cases, funding resources are required to conduct training and build infrastructure (e.g., hiring for new positions). In other cases, thoughtful decisions about reallocating existing resources (e.g., forming work groups, revising decision-making processes) are necessary for building capacity. Securing resources, through solicitation and creative repurposing, to support capacity building demonstrates organizational commitment to health equity.

The tools included for this section can be downloaded on the resources page.

• Organizational assessments
• Building infrastructure
• Staff training and professional development

Example: A Tool for Organizational Capacity Building

BARHII, Local Health Department Organizational Self-Assessment for Addressing Health Inequities
This BARHII organizational self-assessment tool has been used by several local health departments to identify opportunities to advance their health equity work, including building capacity to promote equity in education: http://barhii.org/resources/barhii-toolkit/

Leveraging Institutional Capital for Health Equity Sustainability

When budgeting and funding allocation decisions are made, so too is a statement about the values and priorities of an organization. Institutionalizing health equity requires capital and human resources over an extended period of time, and strategic resource management decisions must be made to ensure that health equity work happens, and continues to happen in the future. Tools have been developed to help institutions attract funding, provide funding, and create budgets for health equity efforts. Because sustainability includes more than just long-term financial security, the long-term sustainability of leadership, vision, people, and momentum must also be considered.

Why Sustainability?

Funding is generally the first consideration that comes to mind when people think about sustainability. It is important that organizations begin the process of strategizing how to keep health equity work ongoing.   Effectively addressing inequities needs long-term commitment, funding, and action. Resources must extend to support activities that help to move broader community change, while maintaining a focus on advancing health equity. While funding resources are critical, they alone do not ensure sustainability of an organization's health equity strategies and programs. Institutionalizing health equity requires a commitment to the long-term support of people and a vision for sustainability. 

Embedding Equity in Practice: Promising Strategies

• Identify your organization's key funding sources and ensure that your entire resource portfolio supports health equity. Wherever possible, an organization should not simply "follow the money" or shift priorities and core objectives to match funding opportunities — its vision and mission should drive the sources of funding. Develop and review your sustainability plan with an equity lens to see where equity is being addressed and where it could be better incorporated. In addition to key funding sources, identify other opportunities that support long-term health equity efforts.
• Focus on sustaining people to keep staff and leadership engaged to do the work. Political winds shift, grant funding eventually ends, and staff sometimes move to other organizations. Amid shifting priorities and transitions, it is important to remain focused on the people who do the work. Sustaining people is about keeping staff and leadership prepared and equipped to do the work, and make the decisions that will help to advance health equity. Mitigating the potential for staff fatigue and burnout, through informal check-ins and adequate staff support, is important.
• Engage the community in meaningful ways to sustain momentum. Authentic involvement from a diverse set of partners helps increase the chances that members of the community will remain involved. Ensure that decision-making structures exist for community members to influence practice and systems change, and provide the necessary support for their participation. Creating meaningful community engagement promotes long-term sustainability — and more involved, stronger and healthier communities — beyond grant cycles and due dates.

The tools included for this section can be downloaded on the resources page.

• Strategies to support health equity funding
• Equitable budgeting practices
• Equitable procurement practices

Example: A Tool for Sustainability

City of Portland, Oregon, Office of Equity and Human Rights, Budget Equity Assessment Tool Template
The City of Portland continues to apply equitable budgeting practices to its work, as evidenced by the mayor prioritizing equity in the city's 2015-16 budget: https://www.portlandoregon.gov/oehr/article/507038
https://www.portlandoregon.gov/oehr/70046

Coalition Building and Partnerships for Health Equity

Coalition building and partnerships are central to the work of advancing health equity. In order to impact the systems and structural determinants of health, as a health equity approach demands, multiple stakeholders, and institutions need to be involved in the process. In addition, community power and decision making are critical aspects of health equity, which values the assets, priorities, and abilities of communities to determine what they need to be healthy. By engaging in these partnerships, public health departments and academic institutions play a pivotal role in helping build community power for health.

Why Coalition Building and Partnerships?

The work of improving systems and community environments requires the collective effort of multiple players who all have a stake in ensuring that all communities, including low-income communities and communities of color, can thrive. Interdisciplinary collaborations are needed more than ever to solve the complex social, economic, and health issues that converge on the lives of everyday residents, particularly for marginalized communities. Building strategic coalitions and multisector partnerships, when rooted in an inclusive, community-driven process, stands as a fundamental strategy to moving the needle on health equity and honoring the wisdom and everyday lived experience of residents. Public health departments, academic centers, and other institutions can play a major role as conveners, facilitators, and capacity builders.

Embedding Equity in Practice: Promising Strategies

• Engage in robust, comprehensive community engagement processes to build trust and accountability. In order for health equity programs or policies to be effective at addressing root causes, they must align with community priorities at the local level. Robust community engagement and participatory processes, at all stages of activity from design to implementation to data collection to evaluation, are crucial to ensure that efforts are responsive to a local context. Conducting not only a community needs assessment, but also identifying assets, strengths, resources, and opportunities within a local community provides a tangible way to engage community leaders and residents in shaping the strategic direction of health equity efforts. 
• Use targeted, proactive approaches to identify diverse stakeholders and unlikely allies to be part of a coalition, partnership, or collaborative. Work to cultivate a diverse base of stakeholders, including those who have been historically excluded from or have been unable to access public policy and advocacy processes. Consider the scope of coalitions and partnerships, such as partners and perspectives at relevant local, regional, state, and national levels. Identify unlikely allies, such as financial partners, faith-based organizations, and other political allies who share common goals.  Develop strategic relationships with elected officials. Clarify roles and responsibilities for each member of a coalition or partnership.
• Implement a model of shared leadership, decision making, and continuous reflection, with clear entry-point opportunities for participation and leadership. Acknowledge the interdependence of roles of members of a partnership or coalition, and build upon each partner’s existing strengths, assets, and resources. Develop a system of tracking and follow-up, with collective accountability for decisions made, actions, and timelines. Work with community members and partners to identify meaningful measures of success, both in process and outcome, and set regular check points for reflection, feedback exchange, and reassessment. 

The tools included in this section can be downloaded on the resources page.

• Community organizing to build partnerships
• Equitable relationship building among diverse stakeholders 
• Establishing shared leadership and power

Example: A Tool for Building Coalitions and Partnerships
CDC,A Practitioner’s Guide for Advancing Health Equity: Meaningful Community Engagement for Health and Equity

This guide provides a list of lessons learned on how to maximize policy and systems change to reduce health disparities and advance health equity. Included in this guide are: lists of key partners, community case studies relating to the implementation of strategies, and examples illustrating how to incorporate health equity into public health: http://www.cdc.gov/nccdphp/dch/health-equity-guide/

Research and Evaluation for Health Equity

Public health departments and academic institutions play a critical role in research and evaluation for public health. Using data and research to understand the root causes of health inequity, and to evaluate and monitor solutions, is key to advancing health equity. Equally important is the way in which research, data collection, and monitoring are conducted. These activities should be done in full partnership with communities in order to ensure that the knowledge generated is accurate, useful, and reflects the values and identity of the impacted community. Finally, it is critical that data and research be action-oriented: it should be shared with and used by those in position to effect change, including social change advocates, policymakers, and organizations seeking to advance health equity initiatives.

Why Research and Evaluation?

Despite the difficulty associated with measuring success and impact, rigorous research and evaluation are important to accurately identify effective strategies, program and policy gaps, and priority needs.  Research and evaluation produce data that can be used to establish goals, benchmark success, and promote innovation.  Because health equity measurement and evaluation remain important development areas for many public health institutions, they must be prioritized.

Embedding Equity in Practice: Promising Strategies

• Incorporate health equity indicators into evaluation plans to measure, track, and demonstrate progress.  Assessment and evaluation of public health programs or interventions is a key function of public health departments and, in many cases, in academic settings. Health equity data indicators can be used to produce information that builds organizational practice around what works rather than problem solving.  Although a standard index of health equity indicators does not yet exist, various examples of health equity, and related data indicators do exist, and can be incorporated into evaluation plans.
• Ensure equitable data collection processes and methods through deep community engagement and community-based participatory research. Strategies to improve health equity occur in a broad social context and over the long term, making it critically important to involve the community in every phase of the research process. In addition to leading and supporting data collection, community members can also be involved in the research planning, analysis, and dissemination processes. Including data from the lived experiences and stories of community members can personalize an issue. Similarly, knowledge translation and dissemination need to occur on a regular basis so that data is accessible to communities.
• Build capacity to use data and evidence more effectively in making the case for health equity. Data serves as a powerful toolfor public health institutions to frame health equity or a relevant issue. Public health departments have been successful in gaining support by leading with data. Equity-minded institutions also work to gain community buy-in during the data collection, analysis, and interpretation process, ensuring that the data is grounded in and reflects community priorities and experiences. While public health practitioners are often equipped with skills in research and data analysis, additional skill building is needed to be able to translate evidence into compelling points that resonate with the audience at hand.

The tools included for this section can be downloaded on the resources page.

• Health equity assessment
• Data collection and monitoring
• Evaluation and accountability
• Community engagement and community-based participatory research (CBPR)

Example: A Tool for Research and Evaluation

Robert Wood Johnson Foundation & The University of Wisconsin Population Health Institute, County Health Rankings & Roadmaps
The Partners for a Healthier Community coalition in Springfield, Massachusetts, used the County Health Rankings model to develop a health equity report as the starting place for their work: http://www.countyhealthrankings.org/roadmaps/projects/health-equity-report-uses-rankings-model-start-dialogue-%E2%80%93-springfield-ma

Framing and Communications for Health Equity

Communications strategies are important for framing issues of health equity in a way that shifts norms, creates space for change, and makes the case for such change. In addition, these strategies are critical for changing the broader narrative of what health means and what communities need to be healthy. The tools and resources in this section will help practitioners and researchers develop health equity communications strategies, employ effective health equity framing, engage in media advocacy, and integrate health equity concepts and language into health proposals.

Why Framing and Communications?

The dominant, medical and individual-level frame often used to describe health disparities has long posed a challenge in public health to focus attention, investments, and activities more upstream to root causes and environmental factors. Changing the way in which the public health community conceptualizes and talks about the root causes of disease and the need for systems change marks a major accomplishment for a number of public health departments and academic centers. Given that the health equity frame explicitly identifies the role of historical and structural racism, institutional bias, and systems of oppression in shaping poor health in communities of color, many health departments must engage in strategic communication strategies to convey the urgency for action towards health equity. Effective framing is important in efforts to advance health equity in that it provides the context within which a message is viewed, understood, and interpreted across different audiences. Consideringwhat language and message, who the audience is, and how the message is delivered are all core parts of an effective communications plan.

Embedding Equity in Practice: Promising Strategies

• Adopt language that reflects communities' core values within a health equity framework. While there is variation in how health equity is defined by institutions, four key areas are commonly included to distinguish the framework from similar and related concepts such as "health disparities" and "social determinants of health." These four components include: a) acknowledgment of (un)fair and (un)just opportunities; b) an explicit mention of race and racism (e.g., the color of one's skin as a predictor of where you live and health outcomes); c) the role of institutional barriers and structural inequalities, often along the lines of race and class; and d) a vision for improved access to resources, opportunity, and power by marginalized groups in order to achieve optimal health.
• Know your audience when developing messages and language. Public health departments and academic institutions engage a diverse range of constituents, partners, and agencies, including those from the public, private, and nonprofit sectors, as well as grassroots, community-based organizations and the residents. These institutions are also situated in unique local contexts that differ by demographic composition, political and social norms, and historical precedents. These institutions must consider these diverse audiences in crafting appropriate messaging and language, particularly for more conservative and wealthier regions where the reality of health inequity may not always be apparent. For example, when Alameda County Public Health Department staff are in a community- based setting, the language they use includes the idea that "every person in Alameda County, no matter the color of their skin, has the opportunity to live a fulfilling life" — in this context, the framing of health equity doesn't need to address all the technical aspects to demonstrate why and how health equity should be achieved.
• Build capacity among staff and partners to change the narrative. In addition to building skills to effectively use data and evidence to frame an issue, public health departments and academic centers can also build staff capacity in strategies to "change the narrative." Many public health practitioners encounter the dominant narrative of individual-level personal choice and behavior in their work, as well as negative stereotypes and biases faced by communities of color. Skills are needed to more effectively shift the narrative towards one that conveys the important role of environment and structural factors. Narrative strategies extend beyond using just data and talking points, but involve critical thinking around the intentionality of messages, using language that tells effective counter-narratives (or stories that debunk commonly held beliefs around power and privilege), and establishing stronger linkages with policy and systems change.
• Work in partnership to develop a media advocacy plan and prepare staff to work with the media. The Berkeley Media Studies Group describes media advocacy as "a public conversation between the advocates and the policymakers held in the media." Effective media advocacy campaigns include an effective "hook" that draws an audience in, make a compelling case for the issue, and link to a tangible form of action to promote a policy agenda. Consider values that resonate with the public and motivate individuals, such as concepts of fairness, family, and justice. When framing an issue, and depending on the audience, utilize a range of social and traditional media platforms, such as a press statement, website or video, case studies, or profiles, in addition to a more formal, in-depth report. Training and professional development in this arena leverage the professional credibility and expertise of practitioners in the field and prepare staff to develop key talking points, anticipate questions, and practice responses.

The tools included for this section can be downloaded on the resources page.

• Building the base
• Messaging and framing
• Media strategies

Example: A Tool for Framing and Communications

Berkeley Media Studies Group, Framing 101
Portrait of Sonoma uses language to frame the health needs and opportunities of residents in terms of equity and opportunity: http://sonomacounty.ca.gov/a-Portrait-of-Sonoma-County/

Policy Advocacy to Institutionalize Health Equity

Ultimately, impact in health equity comes from policy level change, whether to affect the distribution of goods and power in society, or to change the way in which systems operate to allow the conditions for all people to be healthy. Advocacy includes any number of strategies to create social change, from direct action and movement building to working to change government or private sector policies and practices.

Why Policy Advocacy?

Institutionalizing health equity requires policy changes within, and outside of, health institutions.  The long-term systemic changes needed to create the conditions that allow all people to live their full potential, require policy changes.  Although significant, policy changes occur incrementally, and over long periods of time.  Institutions working to advance health equity must build the capacity to engage in policy change work.  In addition, public health leaders must be cultivated to become decision makers, and advance health equity policy both within and outside of their respective institutions.  Several policy advocacy tools have been created that can be adapted to support the adoption of policy that promotes health equity.

Embedding Equity in Practice: Promising Strategies

• Use qualitative and quantitative data to select an issue, identify policy goals, determine strategy feasibility, and make a strong case for health equity. Health equity is institutionalized through both organizational and public policy.  In both cases, it is important that policy strategies selected to advance health equity be based on informed decisions.  Several types of assessment and planning tools have been developed to help public health institutions select the appropriate policy strategy to achieve the desired goals. Data can be used to inform policy strategy, and make the case for policy change approaches to advance health equity.
• Utilize community organizing and base-building tactics to develop long-term strategies. Develop both insider and outsider strategies to exert influence through internal influence and external pressure. Select facilitators who are skilled in guiding conversations with equity principles in mind and can effectively facilitate inclusive processes to develop a shared vision, identify complementary roles, prioritize goals, and engage in issue selection. Identify leverage points for achieving community vision within public agency infrastructure, funding, and operations.

The tools included for this section can be downloaded on the resources page.

• Issue selection and feasibility
• Policy strategy development
• Assessing policy progress and impact

Example: A Tool for Policy Advocacy

Change Lab Solutions, Model Health in All Policies Ordinance
The City of Richmond, California — referenced in this tool — was one of the first American cities to adopt a Health in All Policies Ordinance and strategy to promote health equity through a transformation of city programs, services, data collection, and policy development.