Equity work is crucial for ensuring everyone can reach their full health potential, especially for groups who have been the most excluded and unrepresented. However, many public health professionals have been unsure how to implement practical practices in day-to-day work.
In 2014, 2017, and 2021, the de Beaumont Foundation and the Association of State and Territorial Health Officials conducted the Public Health Workforce Interests and Needs Survey, which “supports the governmental public health workforce by measuring strengths and gaps to inform future investments in funding, training, recruitment, and retention”. In 2021, this survey of over 40,000 state and local government public health employees in the United States found that 34% of all employees named justice, equity, diversity & inclusion highly important to their daily work. This shows many public health professionals are aware of equity concepts but are not confident in addressing them (Porter et al., 2023).
Rebecca Greenleaf, the Director of Learning for the National Maternal and Child Health (MCH) Workforce Development Center, and Dr. Stephen Orton, a Senior Fellow for Public Health Leadership at the North Carolina Institute for Public Health, together have over 50 years of experience working with teams supporting workforce capacity, teaching transformational skills, and developing strategic actions to progress their equity goals. Greenleaf and Dr. Orton understand the frustration of not knowing how or where to start with actualizing equity. To help remedy this, they often teach tools and skills to help teams work toward equity and adaptable to unique needs.
Crafting Narratives and Shifting Power – Originally developed by Human Impact Partners and adapted by the MCH Workforce Development Center, the tool works well with teams focusing on narrow challenges where a known power dynamic or equity issue is in place and the team is ready to explore ways to engage. A major pillar of this tool leans on the power framework and power mapping, adapted from Human Impact Partners.
Is My Public Health Practice Culturally Responsive?
– Originally developed by the Michigan Public Health Institute, this tool is a checklist best for understanding whether equity is at the center of work for an individual, team, and organization at a specific point in time.
Both tools require slowing down and critical reflection to shed some light on the underlying issues creating inequity.
Crafting Narratives and Shifting Power
Dr. Orton begins with assessing the current narrative and questioning why an issue exists to understand how to change that for the future.
A group would use the tool by starting with a problem or inequity that has been noticed or documented. Then, the group figures out two to three policy, legislative, and administrative decisions that historically and currently contribute to the problem. After that, the group describes two to three organizations, institutions, coalitions, alliances, or intermediaries that have had a hand in influencing those decisions. This helps to connect with stakeholders directly involved with these decisions. Lastly, they describe the dominant narrative or story around this inequity. Throughout this process, two key questions can be asked. First, what people/communities are most impacted by the inequity? Second, who benefits (or benefited) from the policies?
By allowing teams to reflect on the power imbalances that are the root causes of inequitable issues, teams can start to address the bigger issues that keep inequities going. Dr. Orten finds leaning into reflection questions as a key to this exercise. These prompts can look like:
- What things do you feel you have less or no influence over? >
- How does this reinforce or challenge power imbalances? >
- What narrative are you projecting about yourself/your organization? >
After this reflection is complete, the next steps are to list two to three things the organization is getting right in their approach to address power in all its dimensions (power to effect structure change, to set the agenda, to change/hold narratives).
The last step in this activity is to list two to three opportunities that can be incorporated into approaches that address power in any of these dimensions.
This tool is designed to be flexible and ongoing. Reframing requires reflection and humility to call out a problem and address how one or an organization upholds inequitable dynamics. Most importantly, this tool encourages people to keep asking questions.
“This is not about fixing our broken selves; this is about leveraging our stronger selves,” said Dr. Orton.
Is My Public Health Practice Culturally Responsive?>
Ensuring work is culturally responsive decreases the chances of creating harm when doing public health work. Greenleaf uses an adapted 38-statement checklist from Michigan Public Health Institute and The Implementation Group, to gauge a point-in-time assessment of equity. This checklist looks at four levels: 1) individual 2) implementation practice, 3) process evaluation, and 4) outcomes evaluations. This checklist measures the degree to which current practices incorporate the principles and methods for conducting work using a culturally responsive and racial equity lens.
This tool is grounded in the concepts of cultural humility and cultural responsiveness. Cultural humility embeds continuous commitment to self-evaluation, addressing power imbalances, and developing mutually beneficial partnerships with the community’s public health work impacts (Tervalon et al., 1998). Cultural responsiveness ensures actions are respectful and relevant to the needs of diverse populations and communities (State of Victoria, Department of Health, 2009). Leaning on these concepts allows for continuous reflection at the individual and the organizational level. Equity is a process and should be part of the entire process of work, from the exploration, installation, initial implementation, and full implementation phases of the work, not something tackled at the end (National Implementation Research Network, 2023).
The first part of this checklist focuses on individual practice and asks the assessor to recognize continuous learning, reflect on personal biases, and support the ‘whole and how’ work is done in teams. The second part looks at team practices. It addresses engaging community partners, assessing and improving processes, and interpreting data. By ranking each statement from zero to five, data can be captured to see which focus areas have equity at its center. After this checklist is completed, implications and action planning can be mapped out. By reviewing the scores, the areas that received higher scores are areas already centering equity. Those with lower scores are opportunities for growth to build equity.
Using this tool regularly allows for better tracking and increased accountability in practicing equity. Greenleaf emphasizes this tool is not just for high-level leaders sitting in a room checking off boxes but for a diversity of perspectives to come together to build cultural responsiveness.
Crafting Narratives and Shifting Power and Is My Public Health Practice Culturally Responsive? are tools that public health professionals can use to bring in equity to daily work. To learn about other resources or discuss these tools further, explore the National MCH Workforce Development Center, to see which tools work for you.
“There are practical tools that you can apply to whatever challenge you’re working on to help you reflect on how you are centering equity in your work, and on where you have opportunities for improvement,” said Greenleaf.
National Implementation Research Network. (2023). Increasing Equity in Education through Stage-based Implementation of Universal Design for Learning in a Multi-Tiered System of Support. https://sisep-center.shorthandstories.com/increasing-equity-in-education/index.html#group-section-Stages-of-Implementation-Smbd18cKPF
Porter, J., Giles-Cantrell, B., Schaffer, K., Dutta, E., & Castrucci, B. (2023). Awareness of and Confidence to Address Equity-Related Concepts Across the US Governmental Public Health Workforce. Journal of Public Health Management & Practice, 29, S87-S97. https://doi.org/10.1097/PHH.0000000000001647
Tervalon, M., & Murray-Garcia, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 117-25. https://doi.org/10.1353/hpu.2010.0233
State of Victoria, Department of Health. (2009). Cultural responsiveness framework: Guidelines for Victorian health services. https://www.health.vic.gov.au/publications/cultural-responsiveness-framework-guidelines-for-victorian-health-services