A P R A C T I T I O N E R'S G U I D E F O R 

ADVANCING HEALTH EQUITY 

Community Strategies for Preventing Chronic Disease 

National Center for Chronic Disease Prevention and Health Promotion 

Division of Community Health 
 

This document was developed by the Centers for Disease Control and Prevention, U.S. Department of Health and Human 

Services and Prevention Institute, with funding support under contract 200-2007-20014 Task 009. The design and published 

components of this document were completed by Ogilvy Public Relations with funding from the Centers for Disease Control 

and Prevention under contract 200-2010-F-33546. 

WWW.CDC.GOV/HEALTHEQUITYGUIDE 

Centers for Disease Control and Prevention 

Division of Community Health 

4770 Buford Highway, NE, Mailstop F-81 

Atlanta, Georgia 30341 

Phone: 770-488-1170 

Fax: 770-488-5964 

Email: cdcinfo@cdc.gov 

Suggested Citation: Centers for Disease Control and Prevention – Division of Community Health. A Practitioner’s Guide for Advancing 

Health Equity: Community Strategies for Preventing Chronic Disease. Atlanta, GA: US Department of Health and Human Services; 2013. 

Disclaimer: A Practitioner’s Guide for Advancing Health Equity is intended as a resource for public health practitioners working to advance 

health equity through chronic disease-focused community health efforts. However, this guide is not intended to reflect the Centers for 

Disease Control and Prevention (CDC) activities or promote strategies that may not adhere to restrictions regarding the use of federal 

investments. 

Additionally, A Practitioner’s Guide for Advancing Health Equity is not intended to serve as step-by-step instructions, as there is no one-sizefits all approach to advancing health equity. Although this document discusses a variety of evidence- and practice-based strategies, it is not 

exhaustive. Strategies included may not be appropriate for every organization’s situation. Communities must decide what is appropriate for 

their local context. Therefore, strategies and examples in this guide should be considered in accordance with an organization’s and, where 

applicable, its funder’s established protocols and regulations. 

In accordance with applicable laws, policies, and regulations, we note that, no federal funds are permitted to be used for impermissible 

lobbying in support of or opposition to proposed or pending legislative matters. Any organization using this guide should be aware of 

restrictions related to their organization’s funding sources when considering the strategies included in this document. For additional 

information on federal restrictions on lobbying for CDC funding recipients using CDC funds, see Anti-Lobbying Restrictions for CDC 

Grantees1 and Additional Requirement #12.2 

Information in this guide does not constitute legal advice. Use of any strategy outlined should only be considered within the context of 

guidance from legal counsel, as appropriate, to ensure compliance with applicable laws and policies. 

Finally, links to non-federal government organizations found in this document are provided solely as a service to the reader. These links do 

not constitute an endorsement of these organizations or their programs by CDC or the Federal Government, and none should be inferred. 

CDC is not responsible for the content of any other Web sites contained in this document. 

cdc.gov/healthequityguide ii
LETTER FROM THE DIVISION OF COMMUNITY HEALTH
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PUBLIC HEALTH PRACTITIONER, 

There is a growing body of literature exploring how environments in this nation shape our health. To address 

this issue, public health practitioners are implementing chronic disease policy, systems, and environmental 

improvements where people live, learn, work, and play. Practitioners are also considering how to ensure such 

improvements are designed to reverse the negative trends of chronic health conditions among vulnerable 

population groups. In response to the mounting needs of practitioners seeking reliable tools to advance health 

equity, the Centers for Disease Control and Prevention (CDC) developed A Practitioner’s Guide for Advancing 

Health Equity: Community Strategies for Preventing Chronic Disease (Health Equity Guide). 

The purpose of the Health Equity Guide is to assist practitioners with addressing the well-documented 

disparities in chronic disease health outcomes. This resource offers lessons learned from practitioners on 

the front lines of local, state, and tribal organizations that are working to promote health and prevent chronic 

disease health disparities. It provides a collection of health equity considerations for several policy, systems, and 

environmental improvement strategies focused on tobacco-free living, healthy food and beverages, and active 

living. Additionally, the Health Equity Guide will assist practitioners with integrating the concept of health equity 

into local practices such as building organizational capacity, engaging the community, developing partnerships, 

identifying health inequities, and conducting evaluations. The Health Equity Guide is designed for the novice 

interested in the concept of health equity, as well as the skillful practitioner tackling health inequities. 

We encourage you to visit WWW.CDC.GOV/HEALTHEQUITYGUIDE for additional tools and resources that 

promote health and the integration of health equity into everyday practice. We hope you find the information 

and examples provided to be useful and an impetus in your efforts to reduce health disparities and advance 

health equity. 

Sincerely, 

Leonard Jack, Jr, PhD, MSc Pattie Tucker, DrPH, RN 

Director, Division of Community Health, (DCH) Acting Associate Director for Health Equity, (DCH)
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National Center for Chronic Disease National Center for Chronic Disease
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Prevention and Health Promotion Prevention and Health Promotion
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(NCCDPHP) (NCCDPHP)
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cdc.gov/healthequityguide iii
TABLE OF CONTENTS 

ACKNOWLEDGEMENTS................................................................................................................................................................ 7
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INTRODUCTION..................................................................................................................................................................................11
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SECTION 1: INCORPORATING EQUITY INTO FOUNDATIONAL SKILLS
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OF PUBLIC HEALTH........................................................................................................................................................................15
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Building Organizational Capacity to Advance Health Equity...................................................................... 16
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Changing the Way They Work to Advance Equity—
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Nashville and Davidson County, TN .....................................................................................................................18
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Meaningful Community Engagement for Health and Equity ...................................................................... 20
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Provide Individualized Attention through Community Networkers—Chicago, IL ........................22
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Developing Partnerships and Coalitions to Advance Health Equity........................................................24
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Intentional Recruitment of Partners Working with Underserved Populations—
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Chicago, IL.......................................................................................................................................................................26
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Identifying and Understanding Health Inequities ..............................................................................................28
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Using Multiple Factors to Pinpoint Health Inequities—Louisville, KY................................................. 30
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Health Equity-Oriented Strategy Selection, Design, and Implementation...........................................32
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A Concentrated, Place-Based Approach to Address Health Inequities—
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Minneapolis, MN........................................................................................................................................................... 34
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Making the Case for Health Equity.............................................................................................................................36
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Mapping Our Voices for Equality—Seattle and King County, WA........................................................38
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Addressing Health Equity in Evaluation Efforts.................................................................................................40
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Setting Up Systems to Understand Who Was Affected—Boston, MA ............................................. 42
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cdc.gov/healthequityguide iv
TABLE OF CONTENTS (Continued) 

SECTION 2: MAXIMIZING TOBACCO-FREE LIVING STRATEGIES 

TO ADVANCE HEALTH EQUITY ........................................................................................................................................... 44
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Comprehensive Smoke-Free Policies ...................................................................................................................... 45
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Native American Tribes Adopt Tobacco Protections for Tribal Members
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and Future Generations—Montana......................................................................................................................47
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Partnerships and Educational Initiatives Lead to Smoke-Free Air Protections—
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Birmingham, AL ........................................................................................................................................................... 48
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Smoke-Free Multi-Unit Housing Policies................................................................................................................ 49
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Creating Healthy Environments through Smoke-Free Multi-Unit Housing Policies—
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San Antonio, TX .............................................................................................................................................................51
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Housing Authority and Public Health Commission Partner on Smoke-Free Housing—
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Boston, MA......................................................................................................................................................................52
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Tobacco Cessation Services...........................................................................................................................................53
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Expanding Cessation Services in Marginalized Communities—St. Louis, MO ................................55
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Using Partnerships to Increase Access to Cessation Services—Santa Clara County, CA.........56
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Point-of-Sale Strategies to Address Access and Exposure to Tobacco Products............................57
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Citywide Restrictions Tackle Flavored Tobacco Products—New York, NY......................................59
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Tobacco-Free Pharmacies Promote Health for All—San Francisco, CA...........................................60
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SECTION 3: MAXIMIZING HEALTHY FOOD AND BEVERAGE STRATEGIES 

TO ADVANCE HEALTH EQUITY .............................................................................................................................................61
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Community Food Retail Environment ......................................................................................................................62
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Corner Store Initiative Supports Community Health and Local Store Owners—
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Philadelphia, PA............................................................................................................................................................ 66
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Improving Food Access and the Local Economy through Farmers’ Markets—
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Southwest Georgia......................................................................................................................................................67
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cdc.gov/healthequityguide v
TABLE OF CONTENTS (Continued) 

Healthy Restaurants and Catering Trucks ............................................................................................................. 68
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Carryout Project Brings Healthful Foods to Low-Income Neighborhoods—
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Baltimore, MD................................................................................................................................................................ 70
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Healthy Hometown Restaurant Initiative—Louisville, KY...........................................................................71
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Healthy Food in School, Afterschool, and Early Care and Education Environments......................72
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Tailored Institutional Practices to Increase Access to Healthy Foods
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in Childcare Centers—Southern Nevada...........................................................................................................74
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Centralized Kitchen Facilitates Healthy Meals for All Schools—Bibb County, GA .......................75
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Food Access through Land Use Planning and Policies ...................................................................................76
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Using Planning and Zoning to Create Access to Healthy and Affordable Foods—
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Buffalo, NY.......................................................................................................................................................................78
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How a Model for Social Change Led to Grocery Stores and a Fast Food Moratorium—
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Los Angeles, CA............................................................................................................................................................79
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Breastfeeding Practices and Policies....................................................................................................................... 80
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Promoting Baby-Friendly Hospitals to Increase Equity—Los Angeles, CA.....................................82
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Building Community Capacity to Support Breastfeeding—New York, NY......................................83
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SECTION 4: MAXIMIZING ACTIVE LIVING STRATEGIES TO ADVANCE HEALTH EQUITY......84
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Joint Use Agreements.......................................................................................................................................................85
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Beyond Conventional Joint Use: Farmers’ Market and Trails in 

Public Housing Communities—San Antonio, TX...........................................................................................87
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Using a School Playground as a Community Resource—Santa Ana, CA .........................................88
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Safe and Accessible Streets for All Users.............................................................................................................. 89
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Creating Safe Routes in a Rural Community—Sault Ste. Marie, MI ...................................................... 91
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cdc.gov/healthequityguide vi
TABLE OF CONTENTS (Continued) 

Transportation Framework Supports Health Equity and Sustainability—
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Multnomah County, OR .............................................................................................................................................92
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Trails and Pathways to Enhance Recreation and Active Transportation ...............................................93
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Trails Upgraded to Better Connect People and Destinations—Mid-Ohio Valley, WV.................95
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Trails and Pathways Increase Connectivity for All in Alabama—
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Jefferson County, AL................................................................................................................................................. 96
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Physical Activity Opportunities in School, Afterschool, and Early Care
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and Education Settings ....................................................................................................................................................97
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Volunteer Services Increase Physical Activity in Afterschool Programs—California ................. 99
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Playworks: Using Recess as a Place to Play and Be Active—Detroit, MI........................................100
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Neighborhood Development that Connects Community Resources to Transit............................... 101
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Addressing Equitable Development through a Health Impact Assessment 

of a Zoning Code—Baltimore, MD......................................................................................................................103
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Job Opportunities and Services Come to a Neighborhood via 

Transit-Oriented Development—Oakland, CA............................................................................................. 104
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Preventing Violence ........................................................................................................................................................ 105
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Building Community Capacity to Foster Healthy and Safe Communities—
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Louisville, KY.................................................................................................................................................................107
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Building a Culture of Peace through Resident Engagement—Boston, MA .................................. 108
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APPENDICES .................................................................................................................................................................................... 109
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REFERENCES.....................................................................................................................................................................................117
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cdc.gov/healthequityguide vii
 

ACKNOWLEDGEMENTS 

This resource was developed with the input and feedback of practitioners and researchers from across the United States. 

We would like to thank all who have contributed to the development and design of A Practitioner’s Guide for Advancing 

Health Equity. The affiliations listed below are those of the contributors at the time of their participation. 

Core Project Team 

CDC expresses sincere appreciation 

to the Core Project Team for the 

development of this resource. 

The Core Project Team’s time, 

expertise, and dedication contributed 

significantly to the vision and 

content of this publication. 

Carolyn Brooks 

Centers for Disease Control 

and Prevention 

Rebecca Bunnell 

Centers for Disease Control 

and Prevention 

Rebecca Payne 

Centers for Disease Control 

and Prevention 

Manal Aboelata 

Prevention Institute 

Dalila Butler 

Prevention Institute 

Virginia Lee 

Prevention Institute 

Shayla Spilker 

Prevention Institute 

Special thanks to Natalie Stahl, 

Centers for Disease Control and 

Prevention; Lesley Guyot, SciMetrika; 

and Menaka Mohan, Prevention 

Institute for their project support 

and coordination. 

Contributing Writers and 

Researchers 

CDC thanks the contributing writers 

and researchers for their diligent and 

thoughtful analyses and reflections 

of the literature and input from 

community practitioners. 

Centers for Disease Control 

and Prevention 

Carolyn Brooks Jennifer Kohr 

Belsie Gonzalez Terry Njoroge 

Joi Hudson Natalie Stahl 

Consultants 

Kim Hodgson, 

Cultivating Healthy Places 

Elva Yañez,
�

Colibri Strategies Inc.
�

Emory University Rollins School 

of Public Health 

Jessica Pittman 

Prevention Institute 

Manal Aboelata Menaka Mohan 

Dalila Butler Janet Pan 

Jeremy Cantor Nicole Schneider 

Sana Chehimi Linda Shak 

Tony Dang Ben Simons 

Rachel Davis Juliet Sims 

Phebe Gibson Shayla Spilker 

Carolina Guzman Sandra Viera 

Virginia Lee Ann Whidden 

Leslie Mikkelsen 

SciMetrika 

Lesley Guyot 

Advisors and Reviewers 

CDC gratefully acknowledges the time, 

dedication, and expertise of the many 

individuals and organizations involved 

in the development and review of A 

Practitioner’s Guide for Advancing Health 

Equity. The insight of these individuals 

has been invaluable in shaping the 

content and ensuring it reflects both the 

practice- and evidence-base. 

Given the range of featured topics, a 

Technical Review Team (TRT) of more 

than 80 individuals representing local 

health departments, community-based 

organizations, national organizations, 

and CDC subject matter experts was 

developed. TRT members contributed 

expertise in health equity, particular 

strategies, specific population groups, 

and/or settings. These individuals 

were engaged at various stages of 

development and participated in various 

ways. Specific TRT members also 

participated on Strategy Review Teams 

for each strategy within the TobaccoFree Living, Healthy Food and Beverage, 

and Active Living sections of the guide. 

These individuals served as the main 

consultative body for the development 

of each respective strategy. The 

individuals listed below contributed to 

sections for which they had expertise. 

However, they are not responsible for the 

final content of the guide. 

cdc.gov/healthequityguide viii
ACKNOWLEDGEMENTS (Continued) 

Centers for Disease Control and Prevention
�

National Center for Chronic Disease Prevention and Health Promotion—
�

National Center for Injury 

Prevention and Control— 

Division of Violence Prevention 

Sarah Bacon Greta Massetti 

Linda Dahlberg Neil Rainford 

Marci Hertz 

Oak Ridge Institute for Science 

and Education Research 

Participation Program at CDC 

W. Brad Jones 

SciMetrika 

Tarisha Cockrell Martha Rider 

Lesley Guyot John Wingfield 

Division of Community Health 

Anna Berkowitz 

Joyce BucknerBrown 

Rebecca Bunnell 

Shannon GriffinBlake 

John Francis 

Shalon Irving 

Leonard Jack, Jr. 

Jennifer Kohr 

Rashid Njai 

Rebecca Payne 

Mark Rivera 

Angela Ryan 

Robin Soler 

Pattie Tucker 

Division of Diabetes Translation 

Larry Alonso Keri Norris 

Division of Nutrition, Physical 

Activity, and Obesity 

Latetia Moore 

Freeman 

Laurence 

Grummer-Strawn 

Sonia Kim 

Joel Kimmons 

Beverly Kingsley 

Carol MacGowan 

Stephen Onufrak 

Terry O’Toole 

Tom Schmid 

Katherine Shealy 

Demia Wright 

Division of Population Health 

Lynda Anderson Holly Hunt 

Sherry Everett- Sarah Lee 

Jones Susie McCarthy 

Office on Smoking and Health 

Steven Babb Brian King 

Bridgette Garrett Michael Tynan 

National Center on Birth Defects 

and Developmental Disabilities— 

Division of Human Development 

and Disabilities 

Jacqui Butler 

National Center for 

Environmental Health 

Daneen FarrowCollier 

Chris Kochtitzky 

Dee Merriam 

Margie Walling 

Arthur Wendel 

Representatives from National and Community Organizations

Linda Aragon 

Los Angeles County Tobacco Control 

and Prevention Program 

Sabrina Baronberg 

New York City Department of Health 

and Mental Hygiene 

Adam Becker 

Consortium to Lower Obesity in 

Chicago Children 

Jim Bergman 

Smoke-Free Environments Law 

Project and The Center for Social 

Gerontology, Inc. 

Elan Bobay 

Monterey County Health Department, 

Steps to Healthier Salinas 

Lorraine Boyd 

New York City Department of Health 

and Mental Hygiene 

Marie Bresnahan 

New York City Department of Health 

and Mental Hygiene 

Isaiah Brokenleg 

Great Lakes Tribal 

Epidemiology Center 

Karen Brawley 

Public Health - Seattle and 

King County 

Hannah Burton 

ChangeLab Solutions 

Vicki Carll 

Pinellas County Health Department 

Caroline Chappell 

North Carolina Division of 

Public Health 

cdc.gov/healthequityguide ix
 

ACKNOWLEDGEMENTS (Continued) 

Serena Chen 

American Lung Association in 

California, Bay Area Smoke-Free 

Housing Project 

Kristin Cipriani 

National Association for Sports 

and Physical Education 

Ann Cody 

BlazeSports America 

Keith Cooper 

American Lung Association, 

Southwest 

Kerry Cork 

Public Health Law Center 

Shannon Cosgrove 

YMCA of the USA 

Dave Cowan 

Safe Routes to School 

National Partnership 

Quang Dang 

ChangeLab Solutions 

Char Day 

Americans for Nonsmokers' Rights 

Daisy DeLaRosa 

Boston Public Health Commission 

Dr. Scout 

Network for LGBT Health Equity 

at the Fenway Institute 

Delbert Elliott 

University of Colorado 

Karen Farley 

California WIC Association 

Mark Fenton 

Mark Fenton Associates 

Catherine Fields 

American Lung Association 

Chione Flegal 

PolicyLink 

Rebecca Flournoy 

PolicyLink 

Barry Freedman 

St. Louis County Department 

of Health 

Roberta Friedman 

Rudd Center for Food Policy 

and Obesity, Yale University 

Christine Fry 

ChangeLab Solutions 

Lark Galloway-Gilliam 

Community Health Councils, Inc. 

Justin Garrett 

American Lung Association in 

California, Center for Tobacco Policy 

and Organizing 

Tony Gomez 

Public Health - Seattle and 

King County 

Priscilla Gonzalez 

Berkeley Media Studies Group 

Bob Gordon 

California LGBT Tobacco Education 

Partnership (LGBT Partnership) 

Christine Green 

National Complete Streets Coalition 

Erin Hagen 

PolicyLink 

Cynthia Hallett 

Americans for Nonsmokers' Rights 

Muriel Harris 

University of Louisville 

School of Public Health and 

Information Sciences 

Alisa Haushalter 

Bureau of Population 

Health Programs 

Kenneth Hecht 

C & K Hecht Consulting 

Seung Hee Lee 

Johns Hopkins University 

Stacy Ignoffo 

Respiratory Health Association 

of Metropolitan Chicago 

Delmonte Jefferson 

National African American 

Tobacco Control Network 

Allison Karpyn 

The Food Trust 

Noelle Kleszynski 

Association of American 

Indian Physicians 

Ingrid Krasnow 

Berkeley Media Studies Group 

Hannah Laurison 

ChangeLab Solutions 

Kathy Lawrence 

School Food Focus 

Mary Lee 

PolicyLink 

Christy Lefall 

Urban Habitat 

Whitney Maegher 

NASBE 

Shireen Malekafzali 

PolicyLink 

Jennifer Moore 

Multnomah County 

Health Department 

cdc.gov/healthequityguide x
 

 

ACKNOWLEDGEMENTS (Continued)
�

Tammy Morales 

Urban Foodlink 

Amanda Navarro 

PolicyLink 

Vu-Bang Nguyen 

Urban Habitat 

Jeannette Noltenius 

Indiana Latino Institute, Inc. 

Faryle Nothwehr 

University of Iowa, College 

of Public Health 

Ana Novais 

Rhode Island Department of Health 

Odessa Ortiz 

Boston Public Health Commission 

Sara Padilla 

Community Food Security Coalition 

Megan Patterson 

Boston Public Health Commission 

Katharine Dupont Phillips 

Nemours 

Lisa Pivec 

Community Health Promotion - 

Cherokee Nation 

Janet Porter 

Break Free Alliance 

Stephanie Ramirez 

National Association of Latino 

Elected Officials 

Kurt Ribisl 

University of North Carolina Gillings 

School of Global Public Health 

Cheryl Richardson 

National Association for Sports 

and Physical Education 

Cynthia Roberts 

Rhode Island Department of Health 

Catherine Saucedo 

Smoking Cessation Leadership 

Center at UCSF 

Sheila Savannah 

Houston Public Health Department 

Regina Schaefer 

American Academy of Pediatrics 

Susan Schoenmarklin 

Attorney and former consultant 

to the Smoke-Free Environmental 

Law Project of the Tobacco Control 

Legal Consortium 

Kevin Schroth 

New York City Department of 

Mental Health and Hygiene 

Dave Shaibley 

Tobacco Control Law Consortium 

Brian Smedley 

Health Policy Institute, Joint Center 

for Political and Economic Studies 

Seth Strongin 

City Project 

Lynnette Swain 

Pinellas County Health Department 

Erika Terl 

National Recreation and 

Park Association 

Mary Thomas 

San Antonio Metropolitan 

Health District 

Abby Thorne-Lyman 

Reconnecting America 

Laurie True 

California WIC Association 

Adrienne Udarbe 

Arizona Department of 

Health Services 

Amanda Wagner 

Philadelphia Department of 

Public Health 

Elizabeth Walker 

National Association of State Boards 

of Education - Center for Safe and 

Healthy Schools 

Y. Claire Wang 

Columbia University, Mailman 

School of Public Health 

Billie Weiss 

Advisor to Safe States Alliance, SAVIR 

Stephanie Weiss 

The Food Trust 

Alzen Whitten 

New York City Department of Health 

and Mental Hygiene 

Missy Wilson 

Mobile County Health Department 

Heather Wooten 

ChangeLab Solutions 

Ellen Wu 

California Pan-Ethnic 

Health Network 

Marc Zimmerman 

University of Michigan 

Additionally, special thanks to the 

many unnamed members of local 

communities presented as examples 

throughout A Practitioner’s Guide for 

Advancing Health Equity. 

CDC would also like to thank ICF 

International, Prevention Institute, 

and Ogilvy Public Relations for their 

support in the development and 

production of the resource. 

cdc.gov/healthequityguide xi
 

 

 

 

Heart disease, cancer, diabetes, and stroke are the most common causes of illness, disability, 

and death affecting a growing number of Americans.4 Many of these chronic conditions 

tend to be more common, diagnosed later, and result in worse outcomes for particular 

individuals,5-7 such as people of color, people in low-income neighborhoods, and others 

whose life conditions place them at risk for poor health. 

(See Appendix A for list of population groups experiencing chronic disease disparities.) 

Despite decades of efforts to reduce and eliminate health disparities, they persist—and in 

some cases, they are widening among some population groups.8-11 Such disparities do not 

have a single cause. They are created and maintained through multiple, interconnected, 

and complex pathways. Some of the factors influencing health and contributing to health 

disparities include the following:12,13

• Root causes or social determinants of health such 

as poverty, lack of education, racism, discrimination, and stigma. 

• Environment and community conditions such as how a community looks (e.g., property 

neglect), what residents are exposed to (e.g., advertising, violence), and what resources 

are available there (e.g., transportation, grocery stores). 

• Behavioral factors such as diet, tobacco use, and engagement in physical activity. 

• Medical services such as the availability and quality of medical services. 

INTRODUCTION 

cdc.gov/healthequityguide 1
 

 

 

 

 

 

INTRODUCTION (Continued) 

HEALTH EQUITY MEANS 

THAT EVERY PERSON HAS 

AN OPPORTUNITY TO 

ACHIEVE OPTIMAL HEALTH 

REGARDLESS OF: 

• THE COLOR OF THEIR SKIN 

• LEVEL OF EDUCATION 

• GENDER IDENTITY 

• SEXUAL ORIENTATION 

• THE JOB THEY HAVE 

• THE NEIGHBORHOOD THEY LIVE IN 

• WHETHER OR NOT THEY HAVE A DISABILITY3 

While health disparities can be addressed at multiple levels, this resource focuses on policy, systems, and 

environmental improvement strategies designed to improve the places where people live, learn, work, and 

play. Many of the 20th and 21st century’s greatest public health achievements (e.g., water fluoridation, motor 

vehicle safety, food safety) have relied on the use of laws, regulations, and environmental improvement 

strategies.14,15 Health practitioners play an important role in these improvements by engaging the 

community, identifying needs, conducting analyses, developing partnerships, as well as implementing 

and evaluating evidence-based interventions. 

These intervention approaches are briefly described below: 

• Policy improvements may include “a law, regulation, 

procedure, administrative action, incentive, or voluntary 

practice of governments and other institutions.”16 

Example: A voluntary school wellness policy that ensures 

food and beverage offerings meet certain standards. 

• Systems improvements may include a “change that 

impacts all elements, including social norms of an 

organization, institution, or system.”17 

Example: The integration of tobacco screening 

and referral protocols into a hospital system. 

• Environmental improvements may include changes 

to the physical, social, or economic environment.17 

Example: A change to street infrastructure that 

enhances connectivity and promotes physical activity. 

cdc.gov/healthequityguide 2
 

 

 

 

 

 

 

 

INTRODUCTION (Continued) 

Such interventions have great potential to prevent and reduce health inequities, affect a large portion of a 

population, and can also be leveraged to address root causes, ensuring the greatest possible health impact 

is achieved over time. However, without careful design and implementation, such interventions may 

inadvertently widen health inequities. To maximize the health effects for all and reduce health inequities, 

it is important to consider the following: 

• Different strategies require varying levels of individual or community effort and resources, which may 

affect who benefits and at what rate. 

• Certain population groups may face barriers to or negative unintended consequences from certain 

strategies (see Appendix B for a list of common barriers). Such barriers can limit the strategy’s effect and 

worsen the disparity. 

• Population groups experiencing health disparities have further to go to attain their full health potential, so 

even with equitable implementation, health effects may vary. 

• Health equity should not only be considered when designing interventions. To help advance the goal, 

health equity should be considered in other aspects of public health practice (e.g., organizational 

capacity, partnerships, evaluation). 

A Practitioner’s Guide to Advancing Health Equity provides lessons learned and practices from the field, 

as well as from the existing evidence-base. This resource offers ideas on how to maximize the effects of 

several policy, systems, and environmental improvement strategies with a goal to reduce health inequities 

and advance health equity. Additionally, the resource will help communities incorporate the concept of 

health equity into core components of public health practice such as organizational capacity, partnerships, 

community engagement, identifying health inequities, and evaluation. 

This resource has four major sections: 

• Incorporating Health Equity into Foundational Skills of Public Health 

• Maximizing Tobacco-Free Living Strategies to Advance Health Equity 

• Maximizing Healthy Food and Beverage Strategies to Advance Health Equity 

• Maximizing Active Living Strategies to Advance Health Equity 

cdc.gov/healthequityguide 3
 

 

TERMINOLOGY 

A clear understanding of definitions is important. The following definitions are offered as 

a starting place as you think through this issue and review this resource: 

Health equity: Health equity is 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.12 

Health disparities: Health disparities are differences in health outcomes and their determinants 

between segments of the population, as defined by social, demographic, environmental, and 

geographic attributes.7 

Health inequalities: Health inequalities is a term sometimes used interchangeably with 

the term health disparities. It is more often used in the scientific and economic literature 

to refer to summary measures of population health associated with individual- or groupspecific attributes (e.g., income, education, or race/ethnicity).7 

Health inequities: Health inequities are a subset of health inequalities that are modifiable, 

associated with social disadvantage, and considered ethically unfair.7,18,19

Social determinants of health: 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.20

cdc.gov/healthequityguide 4
 

 

 

 

 

 

 

Incorporating Equity into Foundational SECTION 1 Skills of Public Health 

Every day, decisions are made that have an influence on health equity. These decisions 

may include who is hired, what activities take place, which populations are served, and how 

strategies are implemented and evaluated. Considering how every decision will impact your 

health equity goals is an important step in integrating health equity into everyday practice. 

This section includes lessons learned from practitioners across the nation who are working 

to advance health equity. Additionally, key questions for reflection are proposed to 

stimulate ideas and help you and your organization think about ways to incorporate the 

goals of health equity into key foundational skills and practices of public health including: 

• Building Organizational Capacity 

• Engaging Community Members 

• Developing Partnerships and Coalitions 

• Identifying and Analyzing Health Inequities 

• Selecting, Designing, and Implementing Strategies 

• Developing Effective Communication Efforts 

• Conducting Evaluations 

cdc.gov/healthequityguide 5
BUILDING ORGANIZATIONAL CAPACITY TO 

ADVANCE HEALTH EQUITY 

ORGANIZATIONS ENGAGE IN MANY PRACTICES – BOTH WITHIN AND BEYOND THEIR 

WALLS – THAT CAN INFLUENCE THEIR IMPACT ON HEALTH EQUITY. EACH OF THESE 

PRACTICES (E.G., HIRING DECISIONS, RESOURCE DISTRIBUTION, STAFF TRAINING) 

REPRESENTS AN OPPORTUNITY TO IMPROVE HEALTH FOR ALL. CONSIDER THESE IDEAS 

TO ENHANCE YOUR ORGANIZATION’S CAPACITY TO ADVANCE HEALTH EQUITY. 

Establish an Institutional Commitment to Advance Health Equity 

Create or clarify your commitment by writing health equity goals into critical documents such as mission 

statements and strategic plans. Support your written commitment with action by establishing permanent 

structures, such as workgroups or staff positions, to improve health equity practices. Create other informal 

systems to empower staff to identify and contribute to health equity-related improvements. Additionally, 

consider conducting an organizational assessment (e.g., Bay Area Regional Health Inequities Initiative

Organizational Self-Assessment Toolkit22) or review your organization’s policies and practices for 

potential modifications. 

Where Possible, Align Funding Decisions with Your Commitment to Health Equity 

Establish or revise processes for seeking, distributing, and using resources. Establish a clear understanding 

of community needs before seeking resources. This will ensure the most efficient use of time and resources. 

Before distributing funds, make health equity a clear component of funding expectations and requirements 

to guide the actions of those receiving the funds (e.g., require hiring and collaborating with representatives 

from underserved communities, require health equity training, develop criteria for prioritizing interventions 

based on need). Also, consider distributing funding opportunities among non-traditional partners and 

conducting trainings to build capacity of potential applicants. 

cdc.gov/healthequityguide 6
Be Deliberate in Recruiting and Building Staff Skills to Advance Health Equity 

Reexamine and expand recruitment efforts through outreach to members of professional affinity groups 

and specific cultural networks. Bring in new skills and perspectives by making experience working with 

underserved populations a priority in job qualifications, and widely distributing job announcements with 

an aim toward engaging staff with skills addressing health equity. Additionally, facilitate ongoing training 

and dialogue among staff and management to help make cultural competency and health equity a part of 

standard operating procedures. 

Track and Capture Health Equity Efforts in Training and Performance Plans 

Establish expectations that staff and management engage in activities designed to advance 

health equity (e.g., training requirements, workgroup participation). Hold staff accountable for 

these activities in training or performance plans. These expectations may help shift the culture 

and clarify everyone’s role in advancing health equity. 

Integrate Health Equity Into Your Services and Resources 

JUSTICE AND THAT OUR ORGANIZATIONAL CULTURE SUPPORTS STAFF IN BEING 

Addressing the complexities of health inequities is beyond the scope of any one organization or entity. 

To build the trust needed to advance health equity, develop multi-sector partnerships and relationships 

with communities affected by health inequities. 

Establish Multi-Sector Collaborations and Relationships with Diverse Communities 

Get feedback from community members to ensure services and resources are culturally and linguistically 

Ensure anticipated improvements are shared 

Also, identify those who are not 

Continually find ways to improve efforts 

appropriate. Modify services, as needed, to make them more convenient for community members (e.g., 

bundle services to reduce number of visits, adjust service hours). 

by tracking those who are benefiting from your services and resources. 

participating and the reasons for this lack of participation. 

with community members to reinforce partnerships and relationships. 

“WE ARE ACTIVELY WORKING TO STRENGTHEN OUR STAFF AND 

ORGANIZATIONAL CAPACITY TO ADDRESS HEALTH INEQUITIES. THIS INCLUDES 

ENSURING OUR INTERNAL WORK IS ROOTED IN THE PRINCIPLES OF SOCIAL 

INNOVATIVE, CREATIVE, PASSIONATE, AND ACCOUNTABLE. BUILDING OUR 

INTERNAL CAPACITY HELPS US DEVELOP STRONG PARTNERSHIPS, ENGAGE IN 

POLICY CHANGE, CONDUCT INNOVATIVE DATA COLLECTION AND ANALYSIS, 

ENSURE OUR PROGRAMS AND SERVICES MEET THE NEEDS OF COMMUNITIES, 

AND WORK IN TRUE PARTNERSHIP WITH COMMUNITIES IN ALAMEDA COUNTY.”21 

— Alameda County Department of Public Health Website 

cdc.gov/healthequityguide 7
 

 

 

 

 

HEALTH EQUITY IN ACTION 

MPHD Staff members participating in a training on community-based focused conversations. 

Changing the Way They Work to Advance Equity—Nashville and Davidson County, TN
�

Metro Public Health Department 

To effectively address existing health inequities, Metro Public Health Department (MPHD) leadership started 

changing the way they worked. The following highlights some of the actions they took to build their 

capacity to advance health equity: 

• MPHD built health equity into its Departmental Strategic Plan in order to institutionalize such work 

throughout the organization. Additionally, in 2012, MPHD’s Director of Health issued a directive to all staff 

to incorporate equity as a decision filter in all policy, programmatic, and practice activities. 

• MPHD established organizational structures, such as a department-wide Equity Work Group to support 

the department in attaining its goals and to ensure continued competency and capacity building. 

• MPHD instituted various professional development and learning experiences to support and advance 

individual competencies and organizational capacity to promote health equity. These experiences 

included assessing individual biases; understanding the impact of individual biases on practice; and 

understanding how societal and structural biases, racism, and diversity impact health status. 

• MPHD worked to build a team of diverse staff who were reflective of and understood the community 

by incorporating a health equity perspective in its hiring practices. Recruitment and interviewing 

processes were modified to hire staff who demonstrated an understanding of health equity and how 

it translated to practice. 

• MPHD continues to foster long-standing relationships with organizations that serve and work with 

communities affected by health inequities. These partnerships are mutually beneficial and have helped 

MPHD more effectively understand and connect to populations of greatest need. 

Through these actions and other efforts, MPHD continues to incorporate a health equity focus in 

everything they do. 

cdc.gov/healthequityguide 8
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

QUESTIONS FOR REFLECTION: Organizational Capacity
�

1. Where are we now? 

How do our current organizational 

policies and practices facilitate or 

inhibit us from advancing health equity? 

What is our organization’s stated commitment 

to health equity? Is this commitment 

documented and widely understood? 

2. How can we institutionalize our organizational 

commitment to advance health equity? 

What process (e.g., organizational 

assessment) can we implement to review 

current policies and practices in relation 

to our health equity commitment? 

How can our current infrastructure 

be enhanced to create accountability 

and provide guidance on our health 

equity commitment? 

What expectations and opportunities exist 

for staff to make health equity a part of their 

daily work? 

3. How can funding decisions advance our 

health equity efforts? 

How do the funds we typically seek 

align with identified health equity needs 

in the community? 

When distributing funds, what funding 

guidelines or requirements need to be 

in place to ensure recipients address 

health equity? 

4. How can we build a skilled and diverse 

workforce committed to health equity? 

How do our recruitment efforts support or hinder 

us in building a diverse staff and management 

team committed to health equity? 

How can we add or enhance our training 

activities to ensure staff and management 

share a common understanding of the 

complexities of health inequities and have the 

skills to advance health equity in their work? 

How can we better align staff performance 

to health equity practice? 

How can we build accountability for 

advancing health equity into the performance 

plans of staff and management? 

5. How can we integrate health equity into our 

products and service offerings? 

What are the cultural and linguistic 

preferences of our community members? 

How can we revise our services and resources 

to accommodate those preferences? 

What structural and operational modifications 

are needed for our services to be more 

accessible and of better quality? 

How are we tracking and evaluating 

our efforts to determine if populations 

experiencing health inequities are benefiting 

from the services or resources we provide? 

6.	� How can our partnerships and community 

outreach efforts help to advance health equity? 

What existing partnerships do we have 

with organizations serving populations 

experiencing health inequities? 

What new partnerships should we 

consider exploring to fulfill our commitment 

to health equity? 

How is our organization perceived in 

the community? 

How can we build better connections to and 

collaborations with populations experiencing 

health inequities? 

7. What are our next steps? 

What can we do differently to improve or 

enhance our organization’s capacity to 

advance health equity? 

What is our plan of action to implement 

those changes? 

cdc.gov/healthequityguide 9
MEANINGFUL COMMUNITY ENGAGEMENT FOR 

HEALTH AND EQUITY 

COMMUNITY ENGAGEMENT CAN HARNESS THE SKILLS AND TALENTS OF A 

COMMUNITY’S MOST IMPORTANT RESOURCE: ITS PEOPLE. INVOLVING COMMUNITY 

MEMBERS IN HEALTH INITIATIVES CAN FOSTER CONNECTEDNESS AND TRUST, 

IMPROVE ASSESSMENT EFFORTS, AND BUILD THE CAPACITY OF INDIVIDUALS TO POSITIVELY 

AFFECT THEIR COMMUNITY. ADDITIONALLY, THIS ENGAGEMENT CAN ENHANCE THE 

EFFECTIVENESS OF PROPOSED STRATEGIES AND INCREASE THE SUSTAINABILITY OF 

EFFORTS. CONSIDER THESE IDEAS TO ENHANCE COMMUNITY ENGAGEMENT ACTIVITIES. 

Understand the Historical Context Before Developing Your Engagement Strategy 

Examine the history of the community as well as past engagement efforts, to understand any issues, and 

to learn what has worked and what has been less successful. For example, years of neglect and conflict 

may have contributed to distrust and prevented meaningful engagement between a community and local 

organizations. Try to get an accurate picture of how your organization and its engagement strategies are 

perceived, and work with community leaders to address any barriers to engagement. 

Build Community Relationships Early On 

Authentic community engagement takes time and requires an ongoing commitment from all involved. 

Establish and maintain strong relationships with communities experiencing health inequities before funding 

opportunities arise or urgent health issues develop. 

cdc.gov/healthequityguide 10
Assess and Address Organizational Barriers to Community Engagement 

Some organizations may be reluctant to begin an engagement process due to the necessary time 

commitment, the staff skills needed, and the ability to demonstrate effectiveness. There may also be 

concerns about the effort becoming unmanageable. To address these concerns, develop engagement 

plans and principles that provide a systematic approach to conducting engagement activities. Additionally, 

consider enlisting the help of other trusted organizations to build staff skills and support engagement efforts. 

Select Engagement Techniques Appropriate for Your Context 

Consider engagement techniques based on the purpose and length of engagement, as well as the resources 

available to your organization. Examples of engagement activities include interviews with community 

members, focus groups, community forums, community assessments and mapping, PhotoVoice, communitybased participatory research, resident participation on boards or councils, and paid positions for residents 

within organizations. 

Understand and Address Barriers That May Prevent Community Participation 

Consider populations that are experiencing health inequities in your community (e.g., people of color, 

people with disabilities, LGBT populations) and potential barriers they may face with engagement efforts. 

Community members often have many demands and may be unclear about the value of their involvement. 

Respect community members’ time and efforts by having a clear and agreed-upon purpose for engagement. 

When necessary, conduct meetings in native languages or provide interpretation or other services needed to 

address language and cultural barriers to participation. Conduct engagement activities at times and places 

that are convenient to the community and provide transportation or childcare services, if needed. 

Support and Build the Community’s Capacity to Act 

Community members are vital assets for broader community improvements and may have a long-term 

interest in the community’s well-being. Choose engagement activities that build on the capacity of 

community members. These activities can increase their awareness of health inequities and provide skills on 

how to intervene. Such engagement activities may include cultivating residents as leaders or supporting local 

coalitions or networks. These efforts can serve a community beyond any one project and can also position 

community members and organizations to apply for additional funding to help sustain efforts. 

Value Both Community Expertise and Technical Expertise 

Many communities benefit from engaging individuals and organizations with technical expertise in certain 

health issues. Such expertise can provide lessons learned from initiatives in other settings, as well as guidance 

to avoid unnecessary barriers in implementation. However, it is critical that the expertise and perspective of 

community members—those ultimately impacted by any initiative—be respected and valued when engaging 

such technical expertise. 

“DON’T LEAVE THE COMMUNITY BEHIND, LET THE COMMUNITY LEAD.”23 

— Lark Galloway Gilliam Executive Director of Community Health Councils 

cdc.gov/healthequityguide 11
HEALTH EQUITY IN ACTION 

A community networker standing adjacent to a community store that supports obesity prevention efforts in Chicago, IL. 

Provide Individualized Attention Through Community Networkers—Chicago, IL 

Consortium to Lower Obesity in Chicago Children (CLOCC) 

In its first decade, the Consortium to Lower Obesity in Chicago Children (CLOCC) decided to focus on 10 

Chicago neighborhoods with disproportionate rates of childhood obesity. These communities were referred 

to as Vanguard Communities and are primarily low-income and communities of color. To make sure the 

consortium developed and implemented effective strategies to reduce such health inequities, CLOCC 

sought out meaningful ways for organizations and individuals in the Vanguard Communities to be involved 

in the design, implementation, and evaluation of obesity-focused initiatives. 

Five community networkers (employed as full-time staff members) served as a direct link to five of the 

Vanguard Communities. Other staffing and partnering models were developed for the remaining five 

neighborhoods. These community networkers served as liaisons between communities and CLOCC, and 

spent the majority of their time in the field engaged in their assigned communities. They brought the needs 

and strengths of the communities to the attention of the consortium. Because the community networkers 

had deep ties to their communities, they understood the context in which activities took place. They were 

able to provide community partners and members with resources, technical assistance, and other relevant 

information from the consortium. 

This model was highly successful in connecting CLOCC to the community and developing a portfolio of 

effective community-based strategies for obesity prevention. As a result, CLOCC refined the staffing 

model and now deploys community program coordinators to serve several regions throughout the city. 

These individuals coordinate resources and bring intervention approaches to many neighborhoods 

throughout Chicago. 

cdc.gov/healthequityguide 12
 

 

 

 

 

 

 

 

 

 

 

 

 

QUESTIONS FOR REFLECTION: Community Engagement
�

1. Where are we now? 

What existing relationships do we have with 

populations experiencing health inequities? 

What is our current process/plan for 

engaging community members, particularly 

those experiencing health inequities? 

Are we using language that facilitates 

or creates barriers to engaging the 

intended communities? 

2. What approaches can we use to effectively 

engage community members? 

What type of engagement techniques do 

we typically use? Have they had the effect 

we intended? 

Are we using techniques that build 

community capacity and leadership? If not, 

what techniques could be pursued? 

3. What barriers to community engagement 

should we consider? 

What is our organization’s history with 

the community? 

What organizational barriers exist 

for meaningful community engagement 

activities? How can we overcome 

these barriers? 

How will we identify barriers to community 

participation? How can we overcome 

these barriers? 

4. How can we engage and balance both 

community and technical expertise in 

our efforts? 

How do we show that we value 

and recognize the expertise of 

community members? 

Do any strained relationships exist in 

the community? Why do they exist? 

How can our engagement process 

best leverage both community and 

technical expertise? 

5. What are our next steps? 

What can we do differently 

to improve or enhance our 

community engagement? 

What is our plan of action to 

implement those changes? 

cdc.gov/healthequityguide 13
 

DEVELOPING PARTNERSHIPS AND COALITIONS TO 

ADVANCE HEALTH EQUITY 

PARTNERSHIPS AND COALITIONS CAN HELP ORGANIZATIONS AMPLIFY THE 

OFTEN UNHEARD VOICES OF POPULATIONS MOST DIRECTLY AFFECTED BY 

HEALTH INEQUITIES. PARTNERSHIPS AND COALITIONS CAN ALSO WORK TO 

ACHIEVE EQUITABLE OUTCOMES BY LEVERAGING A DIVERSE SET OF SKILLS AND 

EXPERTISE. CONSIDER THE FOLLOWING IDEAS TO ENHANCE YOUR PARTNERSHIP 

AND COALITION EFFORTS AROUND ADVANCING HEALTH EQUITY. 

Engage Partners from Multiple Fields and Sectors that Have a Role in 

Advancing Health Equity 

Health inequities do not have a single cause, and public health alone cannot address such inequities. 

Partner with community, education, housing, media, planning and economic development, transportation, 

and business partners, and engage these sectors in your coalition. Such multi-sector partnerships can 

work to improve the underlying community conditions that make healthy living easier, particularly in 

underserved communities. 

Include Partners Working with Population Groups Experiencing Health Inequities 

Organizations dedicated to serving these various populations (e.g., people of color, the elderly, people with 

disabilities, LGBT individuals) may or may not have health-related expertise. However, such organizations 

often have substantial expertise on the norms, culture, and needs of the populations they serve and can 

contribute significantly to your efforts. 

cdc.gov/healthequityguide 14
Establish Mechanisms to Ensure New Voices and Perspectives are Added 

Groups that have been collaborating for a long time should be mindful not to exclude potential new 

partners. Periodically assess membership composition and participation, and evaluate decision-making 

processes. It may also be necessary to periodically adjust meeting times and locations to accommodate new 

partners. While important to ensure a diverse partnership, do not assume that individuals from a specific 

population group can speak for all members of that group. Additionally, be cautious of including community 

representatives as a symbolic gesture rather than as fully engaged partners. 

Develop a Common Language Among Partners from Different Sectors and Backgrounds 

Early in the process, establish a shared vision and understanding for the partnership. Plan discussions or 

trainings to build a common understanding about health equity and the strategies needed to address it. 

Additionally, establish guidelines for communication, such as spelling out acronyms and avoiding potentially 

confusing terminology or jargon. 

Acknowledge and Manage Turf Issues 

— Dr. David Satcher, Director, Satcher Health Leadership Institute and 

the Center of Excellence on Health Disparities, Morehouse School of Medicine 

AN IMPACT. WE MUST REACH OUT TO NONTRADITIONAL PARTNERS IN THE 

All partners should have an equal opportunity to define issues, create strategies, implement solutions, and 

make decisions. The different contributions, resources, and expertise each partner brings to the table could 

be a source of tension or could be leveraged to improve collaborative efforts and outcomes. For instance, 

without additional resources, some partners may not be able to participate on an ongoing basis due to limited 

staff and organizational resources. Finding ways to compensate partners (e.g., funding, continuing education 

credit, travel cost reimbursement, certificates of appreciation) may help provide opportunities for longer-term 

engagement for some partners. Additionally, partners may be able to cross train each other to build skills in 

unfamiliar areas, or they may have complementary resources that can be shared. 

Turf struggles may arise over conflicts in ownership, recognition, or resources between 

organizations. Partners should acknowledge and commit to manage tensions that may arise 

by anticipating potential turf issues, cultivating trust and respect, and shaping a collective identity. 

issues arise, a strong, established relationship can create a safe space for partners to address complex issues, 

If turf 

competing agendas, and difficult decision making. 

Recognize and Address the Power Dynamics in a Partnership 

“OUR PARTNERSHIPS WILL HAVE TO BE STRONGER IF WE ARE TO HAVE 

PRIVATE SECTOR, INDUSTRY, AND OTHER PARTS OF GOVERNMENT IN THE 

TRANSPORTATION, EDUCATION, AND JUSTICE SECTORS, FOR EXAMPLE.”24 

cdc.gov/healthequityguide 15
 

 

 

 

 

HEALTH EQUITY IN ACTION 

Diverse set of community partners who worked together to increase smoke-free protections for vulnerable populations by implementing a 

smoke-free campus at Women’s Treatment Center in Chicago. 

Intentional Recruitment of Partners Working with Underserved Populations—Chicago, IL 

Respiratory Health Association of Metropolitan Chicago (RHAMC) 

To address tobacco-related health inequities, the Respiratory Health Association of Metropolitan Chicago 

(RHAMC) and Chicago Department of Public Health have used various strategies to establish diverse 

partnerships. As part of the partnership process for CDC’s Communities Putting Prevention to Work 

program, they took the following actions: 

• Established a competitive request for proposals (RFP) process to identify and select appropriate partners. 

The RFP process was designed to select partners in diverse geographical areas that demonstrated 

experience in serving populations with disproportionate smoking rates. 

• Promoted the RFP beyond traditional channels, including circulating it among current partners and 

coalitions serving the priority communities. 

• Collaborated with city agencies like the Chicago Park District, Chicago Public Schools, and Chicago 

Housing Authority, as well as community-based social service organizations and community health clinics. 

• Established a system to maintain strong partnerships, tracking efforts in underserved communities, and 

building capacity of community-based organizations through various trainings and technical assistance so 

they could address tobacco use in the future. 

The diverse partnerships developed through this process helped the organization design appropriate 

strategies to address tobacco-related health inequities. 

cdc.gov/healthequityguide 16
 

 

 

 

 

 

 

 

 

 

 

 

 

 

QUESTIONS FOR REFLECTION: Partnerships and Coalitions
�

1. Where are we now? 

How do our current partnerships/coalitions 

reflect the populations experiencing 

inequities in our community? 

What is the current commitment to 

advancing health equity among these 

partners/coalitions? How does this 

commitment translate into identifiable and 

measurable activities? 

2. How can we build diverse and inclusive 

partnerships/coalitions? 

What partners are we missing in our 

network/coalition that should be included? 

What partners do we need to engage 

in order to address the major social 

determinants of health impacting our 

community (e.g., housing, transportation, 

education, urban planning, business)? 

What are the commonalities in the priorities 

of potential partners that can serve as levers 

for collaboration? 

What is each partner’s role in addressing 

health equity? 

3. How can we work to engage new partners in 

a meaningful way? 

What process can we develop to regularly 

assess our partnerships/coalitions to see 

who else should be invited to help advance 

our goals of achieving health equity? 

How can we improve efforts to engage new 

members in meaningful ways? 

How can we strengthen communication and 

understanding among partners? 

4. How can we anticipate and 

address group dynamics that 

may arise? 

What are some of the challenges 

in collaborating with different partners? 

Once identified, what steps can be taken to 

address these challenges? 

What potential issues concern our partners? 

What issues can be anticipated? 

How can we ensure that all partners 

meaningfully participate and influence 

decision making? 

5. What are our next steps? 

What can we do differently to improve or 

enhance our partnerships/coalitions? 

What is our plan of action to implement 

those changes? 

cdc.gov/healthequityguide 17
 

IDENTIFYING AND UNDERSTANDING HEALTH INEQUITIES
�

WITHOUT A CLEAR UNDERSTANDING OF EXISTING HEALTH INEQUITIES, WELLINTENTIONED STRATEGIES MAY HAVE NO EFFECT ON OR COULD EVEN WIDEN 

HEALTH INEQUITIES. IT IS CRITICAL TO HAVE A CLEAR UNDERSTANDING OF 

WHAT INEQUITIES EXIST, AND THE ROOT CAUSES CONTRIBUTING TO THEM. 

CLEARLY IDENTIFY AND UNDERSTAND HEALTH INEQUITIES TO ESTABLISH BASELINES 

AND MONITOR TRENDS OVER TIME, INFORM PARTNERS ABOUT WHERE TO FOCUS 

RESOURCES AND INTERVENTIONS, AND ENSURE STRATEGIES ACCOUNT FOR THE NEEDS OF 

POPULATIONS EXPERIENCING HEALTH INEQUITIES. CONSIDER THESE IDEAS TO ENHANCE 

YOUR ORGANIZATION’S EFFORTS TO IDENTIFY AND UNDERSTAND HEALTH INEQUITIES. 

cdc.gov/healthequityguide 18
Do Not Rely on Assumptions About What Health Inequities Exist in Your Community 

The health inequities in your community may differ from national and state data or other surrounding 

communities. Utilize the best available data to understand what is happening in your community. As 

feasible, follow a thorough process to identify existing health inequities, and assess community assets, 

needs, and challenges. 

Gain a Comprehensive Understanding of the Identified Health Inequities 

Examine multiple aspects of health in your community to get a clearer picture of health inequities. 

For example, identify health risk behaviors and disease outcomes according to characteristics 

such as income, disability status, gender identity, geography, race/ethnicity, and sexual orientation. 

Additionally, gain insight into the social (e.g., discrimination), economic (e.g., poverty), and physical 

(e.g., availability of healthy food retail) environments to develop a deeper understanding of health inequities. 

A community’s history and context (e.g., long-standing policies, cultural norms, values) can also be helpful in 

understanding inequities and identifying effective strategies. 

Use Appropriate Tools to Identify Health Inequities 

National databases, health departments, and institutions, such as universities and hospitals, are prime sources 

for finding local data on health outcomes. While these data sets are a good starting place, you may not 

want to rely solely on this information for understanding health inequities. Partners such as local public 

works, transportation, and police departments may have access to other data sources (e.g., water quality, 

street conditions, crime statistics) which may reveal inequities related to social, economic, and physical 

environments. Where possible, use data sources that allow you to stratify indicators by factors such as age, 

disability status, race, and sexual orientation. See Appendix C for a list of online resources for identifying 

and understanding health inequities. 

Engage Community Members and Partners in Data Collection and Interpretation 

Provide training to community members to enable them to participate in data collection activities (e.g., 

community asset mapping, PhotoVoice, digital storytelling, walking audits). Once data are collected, 

community members and partners can also be included in interpreting findings, refining priorities, and 

developing solutions. The perspectives of community members can bring static data to life by revealing 

the lived experiences behind the data. 

cdc.gov/healthequityguide 19
HEALTH EQUITY IN ACTION
�

Map of Louisville, KY used as a tool to identify inequities. 

Using Multiple Factors to Pinpoint Health Inequities—Louisville, KY 

Louisville Metro Public Health and Wellness 

The Louisville Metro Public Health and Wellness (LMPHW) Department is committed to reducing obesityrelated health inequities. To identify areas with higher rates of obesity, the department analyzed data 

related to the social determinants of health including income, violence, access to transportation, and 

access to healthy food (including proximity to fast food restaurants). It also used GIS mapping to identify 

and locate relevant indicators by ZIP code. 

These strategies revealed that obesity rates and environments that did not support healthy eating and 

physical activity in Louisville were disproportionately higher in 12 low-income neighborhoods—most 

of which were also predominantly African American. These neighborhoods are characterized as food 

deserts, where affordable, healthy food is difficult to obtain. These neighborhoods also have higher rates 

of violence and poverty and low levels of education. Having a clear emphasis on areas experiencing 

health inequities helped the department to design its initiatives and focus their efforts accordingly. 

cdc.gov/healthequityguide 20
 

 

 

 

 

 

 

 

 

 

 

 

 

QUESTIONS FOR REFLECTION: Health Inequities
�

1. Where are we now? 

What are our organization’s current 

practices for identifying and understanding 

health inequities? 

Can we clearly articulate health inequities 

related to the health issues we are trying 

to prevent and/or address? If so, list those 

health inequities. 

2. What types of information can we use to 

identify health inequities in our community? 

What process can we set up to get a 

full understanding of health inequities in 

our community? 

What type of information do we need to 

ensure we have a full understanding of 

health inequities in our community? 

Have we looked beyond basic health risk 

behaviors and standard outcome data to 

examine social, economic, and physical 

indicators that may contribute to or 

maintain health inequities? 

Have we examined community context 

and historical factors that may help our 

understanding of existing health inequities? 

3. What tools and resources can we use to 

identify and understand health inequities? 

What combination of data sources do we 

need to better understand experiences of 

populations affected by health inequities? 

What sources or partners may already have 

the data we need for assessing community 

environments or health behaviors? 

Where can we go to understand the 

historical context of health inequities in 

the community? 

4. How can we engage community members in 

gathering and analyzing data? 

How do we currently engage community 

members in our data collection and 

analysis process? 

What process can we put in place to 

routinely engage populations affected 

by health inequities in collecting and 

analyzing data? 

5. What are our next steps? 

What can we do differently to 

improve or enhance our ability to identify 

and understand health inequities? 

What is our plan of action to implement 

those changes? 

cdc.gov/healthequityguide 21
 

HEALTH EQUITY-ORIENTED STRATEGY SELECTION, 

DESIGN, AND IMPLEMENTATION 

WITHOUT A DELIBERATE FOCUS ON HEALTH EQUITY IN THE STRATEGY 

DEVELOPMENT PROCESS, STRATEGIES MAY UNINTENTIONALLY WIDEN HEALTH 

INEQUITIES. WELL-DESIGNED STRATEGIES CAN INCLUDE SUPPORTIVE ACTIVITIES 

TO ADDRESS BARRIERS OR UNINTENDED CONSEQUENCES UNDERSERVED 

POPULATIONS MAY FACE DURING IMPLEMENTATION. SUCH EFFORTS CAN HELP ENSURE 

MAXIMUM EFFECTS ACROSS COMMUNITIES EXPERIENCING HEALTH INEQUITIES. CONSIDER 

THESE IDEAS TO ENHANCE STRATEGY DEVELOPMENT EFFORTS. 

Balance Community Input and Best Available Evidence 

Without community input, there can be challenges with strategy design, implementation and enforcement. 

Build community ownership in the very beginning of this process to increase the effectiveness and 

sustainability of strategies. Additionally, examine the best available evidence to ensure that your community 

is investing resources and time in strategies that are most likely to have the intended impact. 

Establish a Process to Ensure Strategies are Linked to Identified Inequities 

Given the multiple factors involved in developing and implementing strategies, efforts can sometimes 

unintentionally shift away from identified population groups. Ensure strategies are aligned with desired 

outcomes by writing goals that outline identified inequities. Consider developing criteria or questions to be 

used as a guide for examining all strategies. This ensures the criteria and strategies align with the established 

health equity goals. (See Appendix D for a sample Health Equity Checklist.

25) 

Select a Comprehensive Set of Approaches 

Consider selecting a comprehensive set of strategies that work together, as one strategy in isolation only goes so far. 

For instance, while a policy improvement can be impactful, it may need to be supported by educational activities or 

organizational improvements to have the intended effect on populations experiencing health inequities. 

Account for the Diversity Within the Community 

Understand the diversity within your community (e.g., age, disability status, geographic area, race/ethnicity, 

sexual orientation, socioeconomic status). Populations may have different needs that should be considered 

and accounted for in strategy selection, design, and implementation (e.g., financial incentives, language 

translation, mobility assistance). Such diversity may also reveal the need for a wide set of partners in the 

design process. 

cdc.gov/healthequityguide 22
 

 

 

 

 

 

 

Recognize that Everyone is Not Starting at the Same Place 

Populations experiencing health inequities may have further to go to fully benefit from a given strategy. 

Identify and account for different levels of existing resources, capacity, and support across population groups 

when designing strategies to help avoid widening health inequities. 

Identify Barriers and Potential Negative Unintended Consequences that Populations 

Experiencing Inequities May Face 

When designing strategies, consider and account for possible barriers to full implementation, enforcement, and 

benefit for populations experiencing health inequities. Additionally, anticipate negative unintended consequences 

of any strategy and incorporate solutions early in the design phase. Common barriers may include cost, 

transportation challenges, safety concerns, lack of capacity or resources, lack of awareness, differing social or 

cultural norms, and limited health literacy. Potential unintended consequences may include stigma or displacement. 

Work with partners and community members to identify potential barriers and negative consequences and build in 

support to address them. (See Appendix B for a description of potential barriers and unintended consequences.) 

Use a Tool to Ensure Health Equity is Part of Strategy Selection and Design 

Using tools or frameworks can help you think through health equity considerations in each step of strategy 

selection and design. Such tools can also ensure consistency in planning and help align strategies with 

health equity goals. You can use an existing tool (e.g., Health Impact Assessment26 and Health Equity Impact 

Assessment27) or you can work with partners and the community to develop your own tool. 

Establish Processes to Identify and Address Implementation Challenges 

It can be difficult to fully measure the effect of a strategy until it is completed. However, you can build in 

opportunities to monitor progress at different stages of implementation to identify issues and assess how well 

populations experiencing health inequities are being reached. Identify issues early in the process to provide 

an opportunity to make adjustments that can support equitable outcomes. Be prepared to address potential 

challenges and provide additional supports throughout a strategy’s implementation. 

CONSIDER THE FOLLOWING OVERARCHING QUESTIONS WHEN DESIGNING 

STRATEGIES TO ADVANCE HEALTH EQUITY: 

• Are those most affected by the issue actively involved in defining the problem and shaping 

the solution? 

• How does this strategy improve the conditions for those communities most in need? 

• Will those most negatively affected by the problem benefit the same, less so, or more so? 

• What barriers or unintended consequences should be accounted for to make this strategy 

effective in underserved communities? 

• How can we ensure effective implementation and enforcement of identified strategies across 

population groups or communities? 

cdc.gov/healthequityguide 23
 

 

 

 

 

 

HEALTH EQUITY IN ACTION 

Nice Ride bike kiosk located at Farview Park in north Minneapolis, MN – an area with high rates of obesity and physical inactivity. 

A Concentrated, Place-Based Approach to Address Health Inequities—Minneapolis, MN 

Minneapolis Department of Health and Family Support (MDHFS) 

With support from CDC’s Communities Putting Prevention to Work program, the Minneapolis 

Health Department (MHD) developed a series of strategies focused in North Minneapolis to address 

disproportionate rates of obesity and limited access to physical activity and healthy food resources. 

The Health Department and partners implemented the complementary initiatives listed below: 

• Placed bike share kiosks next to parks where MHD outreach workers encouraged families to use 

neighborhood parks for physical activity. 

• Located the kiosks and the new bike walk center near mass transit as well as bike lanes and walking paths 

to link residents to major community destinations including farmers markets, community gardens, and 

commercial districts. 

• Implemented Safe Routes to School in the same areas to increase opportunities for students to walk and 

bike to school. 

• Used targeted media, advertising, and outreach to increase residents’ awareness of biking and walking 

resources and how the strategies connected to other health initiatives. 

• Implemented Electronic Benefit Transfer (EBT) systems and a Market Bucks incentive program at farmers’ 

markets in the area, allowing residents to use EBT cards to purchase fresh fruits and vegetables and 

providing customers with up to a $5 match in Market Bucks coupons. 

• Established a local food resource hub and network in four neighborhoods, including North Minneapolis. 

In this place-based approach, each strategy complemented the other, resulting in a focused effort to reduce 

health inequities. 

cdc.gov/healthequityguide 24
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

QUESTIONS FOR REFLECTION: Strategy Selection, Design, and Implementation
�

1. Where are we now? 

What is our current process, if any, for 

integrating health equity into strategy 

selection, design, and implementation? 

2. How can we address health equity 

goals when selecting strategies? 

What are the diverse needs we 

should consider when selecting 

strategies that will have the greatest 

impact on populations experiencing 

health inequities? 

How can we balance community input 

with evidence-based strategies to select 

the most effective strategies to reduce 

health inequities? 

How can we verify that selected strategies 

align with the needs of populations 

experiencing health inequities? 

How can we ensure selected strategies build 

on one another to form a comprehensive 

approach that advances the achievement of 

health equity in our community? 

3. How can we address our health equity goals 

when designing strategies? 

What are the diverse needs we should 

consider when designing strategies that will 

have the greatest impact on populations 

experiencing health inequities? 

How can we account for different levels 

of existing resources, capacity, and 

supports across population groups when 

designing strategies? 

What process can we establish to identify 

and address barriers to, and potential 

unintended consequences of strategies that 

populations experiencing health inequities 

may face? 

4. What tools can we use to select and design 

strategies to advance health equity? 

What existing processes, frameworks, 

and/or tools can we use to systematically 

incorporate the goal of health equity into 

strategy selection and design? 

What processes or tools can we create to 

systematically incorporate the goal of health 

equity in all of our strategy selection and 

design efforts? 

5. How can we address our health equity goals 

when implementing strategies? 

How can we work with partners to 

anticipate needs among populations 

experiencing inequities and provide 

necessary supports to advance 

equitable outcomes? 

What methods have we put in place to 

monitor progress in implementation, identify 

issues early in the process, and assess 

how well populations experiencing health 

inequities are being reached? 

What agreements have we reached with our 

partners on the long term plans and results? 

6. What are our next steps? 

What can we do differently to improve or 

enhance our strategy development process 

to advance health equity? 

What is our plan of action to implement 

those changes? 

cdc.gov/healthequityguide 25
MAKING THE CASE FOR HEALTH EQUITY
�

THERE ARE VARYING IDEAS ABOUT WHAT IT MEANS TO “ADVANCE HEALTH 

EQUITY.” EFFECTIVELY MAKING THE CASE FOR HEALTH EQUITY REQUIRES AN 

UNDERSTANDING OF THE COMMUNITY CONTEXT AND INTENDED AUDIENCES, 

AN APPROPRIATELY FRAMED MESSAGE THAT APPEALS TO CORE VALUES, AND INCREASED 

AWARENESS OF EXISTING HEALTH INEQUITIES AMONG STAKEHOLDERS. CONSIDER THESE 

IDEAS TO ENHANCE EFFORTS IN MAKING THE CASE FOR HEALTH EQUITY: 

cdc.gov/healthequityguide 26
Assess the Community Context Before Developing Messaging Around Health Equity 

Without a proper understanding of the community context, messages around health equity can go 

unnoticed or may lead to unfavorable actions. It is important to consider the needs, assets, and priority 

issues of both community members and key stakeholders. Also, consider their receptiveness to the 

concept of health equity before developing any messaging. Understanding these issues may provide 

insight into common values, competing demands, fiscal priorities, and related efforts, which may help in 

refining messages. 

Leverage Opportunities to Advance Health Equity Efforts 

Become aware of health equity-related work in your area and around the country. If health equity-oriented 

efforts are underway, connect with those efforts to heighten the visibility of your efforts and to reinforce 

your message. Additionally, identify partners or coalitions with complementary goals (e.g., community- and 

faith-based organizations) as they may be able to support your message. 

Support the Case for Health Equity with Relevant Data 

Use data on health inequities to complement your overall message and raise the awareness of 

key stakeholders. For example, visual and experiential data (e.g., mapping, digital storytelling) can 

provide vivid examples of the real experiences of communities affected by health equities. Cost 

data can also be used to reveal the significant financial implications of existing inequities (e.g., unnecessary 

health care costs, costs associated with premature death among populations experiencing inequities). 

Highlight Solutions When Framing Your Messages Around Health Equity 

Lengthy descriptions of the existence of health inequities may detract from actionable solutions. 

The description of the problem should not overshadow potential solutions. Establish which inequities 

exist in your community; however, ensure the message focuses on actions to address health inequities.
�

Ensure Health Equity Messages are Appropriately Disseminated 

It is important that everyone from staff and community members to partners and stakeholders have a 

shared understanding of your health equity goals. Provide trainings to equip staff members with a clear 

understanding of health equity as they are the voices for advancing your organization’s efforts. Create 

opportunities for dialogue among community members and stakeholders to share concerns and develop 

skills to advance health equity in their communities. Identify ways to connect your partners’ broader 

networks to ensure diverse perspectives are contributing to solutions for health equity. Use a variety of 

communication methods (e.g., earned media, radio spots) to both broadly disseminate and appropriately 

tailor your messages. 

cdc.gov/healthequityguide 27
 

 

 

 

 

HEALTH EQUITY IN ACTION
�

Mapping Our Voices for Equality—Seattle and King County, WA 

Public Health Seattle & King County (PHSKC) and Partners 

Mapping our Voices for Equality (MOVE)28 uses media to promote health equity in Seattle and King 

County. MOVE combines over 100 community-developed multilingual digital stories and features a local 

map showing both the impact of place on health and some place-based changes that will improve health 

in King County. To implement MOVE, Public Health Seattle & King County (PHSKC) with support of CDC’s 

Communities Putting Prevention to Work program, did the following: 

• Engaged community members in dialogue about health equity issues and provided workshops on digital 

storytelling to gather stories, empower community members, and promote positive health changes in 

King County. 

• Invited local stakeholders to community meetings and forums where community members could 

showcase their videos and have a discussion. 

• Posted over 100 multilingual digital stories to a website with widespread reach, encouraging other 

community members to get involved. 

• Created templates and worksheets to foster dialogue among key stakeholders and community groups 

when holding meetings and health equity discussions. 

• Successfully contributed to multiple policy, systems, and environmental improvements including 

enhanced school nutrition policies, increased hours to a local community center, and increased access to 

healthy food in a local "food desert." 

The MOVE media initiative is empowering community members to identify and raise awareness of the 

health inequities impacting them. 

cdc.gov/healthequityguide 28
 

 

 

 

 

 

 

 

 

 

 

 

 

 

QUESTIONS FOR REFLECTION: Making the Case for Health Equity
�

1. Where are we now? 

How do we currently frame our 

efforts regarding health equity; 

what are our messages? 

2. How can we assess the community context 

to develop our health equity messages? 

How receptive are our key stakeholders 

toward adopting a health equity approach? 

What are the views and perceptions of our 

key stakeholders as they relate to health 

inequities? How should we consider those 

views in our messaging? 

Are other activities and ongoing efforts 

occurring in our community that could 

support or inhibit a health equity-based 

approach? How can we build on these 

supportive activities and overcome 

challenges to implementing a health equitybased approach? 

How can we identify and connect with 

potential partners/coalitions currently 

engaged in health equity-focused work? 

3. What type of data can we use to support the 

case for health equity? 

What are some creative ways to capture 

and highlight the lived experience of health 

inequities in our community? 

What combinations of data can we use to 

help make the case for health equity? 

4. How can we share our message about health 

equity? 

How can we ensure our staff and partners 

have a common understanding of our work 

to advance health equity? 

What are the key messages needed to tell 

the health equity story in our community? 

How can we create a dialogue around health 

equity among community members and 

other key stakeholders? 

Which communication methods will be most 

effective to reach our intended audiences? 

How can we identify and communicate our 

health equity success stories? 

5. What are our next steps? 

What can we do differently to improve or 

enhance our ability to make the case for 

health equity? 

What is our plan of action for implementing 

those changes? 

cdc.gov/healthequityguide 29
ADDRESSING HEALTH EQUITY IN EVALUATION EFFORTS
�

WITHOUT A FOCUS ON HEALTH EQUITY IN EVALUATION EFFORTS, THE EFFECTS 

OF AN INTERVENTION ON ADDRESSING HEALTH DISPARITIES AND INEQUITIES 

CAN GO UNNOTICED. FOR EXAMPLE, AN EVALUATION MAY REVEAL OVERALL 

IMPROVEMENTS IN HEALTH, BUT OVERLOOK THE FACT THAT HEALTH DISPARITIES 

OR INEQUITIES ARE WIDENING. HEALTH EQUITY-ORIENTED EVALUATIONS CAN BE DESIGNED TO 

UNDERSTAND WHAT WORKS, FOR WHOM, UNDER WHAT CONDITIONS, AND REVEAL WHETHER 

HEALTH INEQUITIES HAVE DECREASED, INCREASED, OR REMAINED THE SAME. INTEGRATE 

HEALTH EQUITY CONSIDERATIONS THROUGHOUT EACH STEP OF AN EVALUATION TO MORE 

ACCURATELY INTERPRET FINDINGS AND EFFECTIVELY FOCUS INTERVENTIONS. CONSIDER 

THESE IDEAS TO INTEGRATE HEALTH EQUITY GOALS INTO YOUR EVALUATION EFFORTS. 

Develop a Logic Model That Includes Health Equity Activities and Goals 

Guide implementation and evaluation efforts by documenting your health equity-related process activities 

and outcome goals in your logic model. Include these goals and activities to provide clarity on your intended 

effects on health equity. Secure buy-in and participation by engaging diverse stakeholders, including 

community members experiencing health inequities, in the development of the logic model. Also include them 

in every other step of the evaluation process. 

Incorporate Health Equity into Evaluation Questions and Design 

Since evaluation questions guide the evaluation process, it is critical that your health equity goals are reflected 

in them. Such questions may help you determine what has worked for whom and under what conditions. 

Additionally, consider indicators of success at all stages of the logic model to assess whether an intervention 

reached the intended population, was implemented correctly, and had the intended outcome(s). 

Identify Appropriate Variables to Track Populations Experiencing Inequities 

Appropriate variables and strategic sampling plans are needed to assess differential effects of interventions 

across population groups or settings. Choose relevant variables (e.g., income, race, zip code) early in the 

process to ensure sufficient data on populations experiencing inequities will be gathered, tracked, and analyzed. 

In addition, carefully select sites/settings or participants that are to be included in the sampling frame. 

cdc.gov/healthequityguide 30
 

Use Culturally Appropriate Tools and Methodologies 

Evaluations may be planned and carried out by individuals with different educational backgrounds, primary 

languages, and cultural identities than the populations experiencing health inequities. Therefore, gather the 

best possible data by using culturally appropriate tools and methodologies that consider factors such as the 

population’s language needs, literacy levels, and facilitator preferences. 

Use Multiple Approaches to Understand an Intervention’s Effect on Health Inequities 

One approach may not sufficiently account for the complexities of health inequities or reflect issues and 

successes identified as important by the community. Consider multiple approaches (e.g., GIS analysis, focus 

groups, assessment of environmental improvements) to understanding an intervention’s effect to broaden the 

range of credible evidence, create new measurement models, and integrate new voices into the understanding 

of a strategy’s effects. Additionally, consider a long-term plan for data collection, as it takes time to change the 

underlying factors that contribute to health inequities. 

Include Health Equity Indicators Into Performance Monitoring Systems 

Performance monitoring systems may be revised or developed to track whether changes occur 

in places where they are most needed, as well as other efforts to advance equity. Such tracking 

provides an opportunity to monitor progress, identify necessary mid-course corrections in 

underserved communities, and answer questions that may emerge as the evaluation proceeds. 

“UNLESS THERE IS A DELIBERATE INTENTION TO ADDRESS HEALTH INEQUALITIES 

Knowing what works, what does not work, and what may have promise is essential to expand the type of 

interventions being used to advance health equity. Contribute to the evidence-base by sharing findings, 

particularly if results identified disparate effects, such as an increase in health inequities. Additionally, build 

capacity and increase awareness among community members and stakeholders by sharing findings and 

providing the data they need to decide on next steps. 

Use process evaluation to gather information about the planning, engagement, and implementation of a 

strategy. These data may later help explain successful (or unsuccessful) outcomes as they relate to health 

inequities. Outcome evaluations can be used to understand the effect of an initiative across different 

populations and indicate whether health inequities have decreased, increased, or remained the same. 

Incorporating health equity implications in both process and outcome components of an evaluation can 

help explain an intervention’s effect on health inequities. 

Use Process and Outcome Evaluations to Understand the Effect on Health Inequities 

Widely Disseminate the Results of Equity-Oriented Evaluations 

AND TO BUILD UP EVALUATIONS THAT PURPOSEFULLY USE EQUITY AS A VALUE 

CRITERION, THE FIELD OF HEALTH PROMOTION MAY GO ASTRAY REGARDING ITS 

UNDERLYING COMMITMENTS TO EQUITY IN HEALTH.”29 

— Louise Potvin, Université de Montréal 

cdc.gov/healthequityguide 31
 

 

 

 

 

HEALTH EQUITY IN ACTION 

Setting Up Systems to Understand Who Was Affected—Boston, MA 

Boston Public Health Commission (BPHC) 

The Boston Public Health Commission (BPHC) worked to ensure their Communities Putting Prevention to 

Work (CPPW) efforts were effective in reaching the populations experiencing obesity and tobacco-related 

health inequities. BPHC implemented the following steps in developing their evaluation plan: 

• Developed evaluation questions to gauge their impact on health inequities. 

• Required partners to routinely collect data on race/ethnicity, age, gender, and zip code for all of 

their initiatives. The data documented how activities benefitted the community in general, as well as 

population groups/areas experiencing health inequities. 

• Increased sample size for the CPPW Behavioral Risk Factor Surveillance System in order to ensure 

sufficient power to assess neighborhood-level changes over time. 

• Designed an analysis plan to assess the overall effect of the selected strategies, as well as the effect(s) 

across population groups. 

• Set up their performance monitoring to identify areas where additional efforts may be needed to enhance 

intervention effects in underserved communities. 

This strategic evaluation design enabled BPHC to make mid-course adjustments and enhanced their ability 

to contribute to the evidence-base regarding the influence of their initiative on advancing health equity. 

cdc.gov/healthequityguide 32
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

QUESTIONS FOR REFLECTION: Addressing Health Equity in Evaluation Efforts
�

1. Where are we now? 

How are we currently assessing the effect(s) of 

our efforts to address health equity? 

2. How do we start the evaluation 

process with health equity in mind? 

Do we have the expertise to develop, implement, 

and assess an equity-oriented evaluation plan? 

What process can we establish to routinely 

engage community stakeholders, including those 

experiencing health inequities, in all aspects of 

our evaluation efforts? 

What are our current health equity strategies, 

activities and goals? 

How can our logic model be modified to reflect 

our health equity activities and goals? 

3. How can we consider health equity in evaluation 

questions and design? 

How can we reframe or create new evaluation 

questions to better understand our effect on 

health inequities? 

What are the key variables we should use to 

track the influence of our efforts on populations 

experiencing health inequities? 

How can our sampling plan be designed or 

modified to answer our health equity-oriented 

evaluation question(s)? 

4. How can we integrate health equity principles in 

the data gathering process? 

What processes do we have in place to 

determine when culturally appropriate tools or 

methodologies are needed? 

If modifications are needed, how can we 

ensure our evaluation tools meet the needs of 

populations experiencing health inequities (e.g., 

language and literacy needs)? 

Are the data we are collecting reflective of the 

real experience of the populations experiencing 

inequities? Are other approaches needed? 

Does our performance monitoring system allow us 

to track and identify needs that may arise when 

implementing efforts in underserved communities? 

How can we structure our evaluation processes 

to understand the long-term effects of our efforts 

on health inequities? 

5. How can we understand our effect on health 

equity through our analysis plan? 

Does our analysis plan allow us to answer 

the following: 

• What worked? 

• For whom? 

• Under what conditions? 

• Is there any differential impact? 

• Have inequities decreased, increased, or 

remained the same? 

If not, how can we modify the analysis plan to 

answer these questions? 

Does our outcome evaluation allow us to determine 

differential effects across population groups? 

Does our process evaluation allow us to 

understand the key factors that influenced 

the outcomes of our efforts in underserved 

communities? 

What actions do we need to take to improve or 

enhance our evaluation plan to understand our 

effects on health equity (e.g., have inequities 

decreased, increased, or remained the same)? 

6. How can we share our evaluation efforts with 

diverse stakeholders? 

How and where do we typically disseminate our 

evaluation findings? 

What commitment can we develop to ensure we 

share findings, even if negative? 

How can we ensure we share our findings in plain 

and clear language that can be understood by 

stakeholders, partners, and community members? 

How can our findings be used to support more 

action in communities of greatest need? 

How can we revise the ways in which we share 

lessons learned to help others concerned with 

addressing health inequities? 

7. What are our next steps? 

What can we do differently to improve or 

enhance our ability to conduct health equityoriented evaluations? 

What is our plan of action to implement 

improvements in our evaluation efforts? 

cdc.gov/healthequityguide 33
’ 

 

 

 

 

 

 

 

 

 

SECTION 2 Maximizing Tobacco-Free Living 

Strategies to Advance Health Equity
�

Despite overall declines in cigarette smoking, some population 

groups have disproportionately higher rates of smoking. These 

groups include certain racial/ethnic minority groups, particularly 

American Indians/Alaska Natives; those with low socioeconomic 

status; those with mental health and substance abuse 

conditions; those in the lesbian, gay, bisexual, and transgender 

communities;30 and those with disabilities.31 Identifying and 

eliminating tobacco-related health inequities among population 

groups is an important component of tobacco control efforts.32 

The Tobacco-Free Living section of A Practitioner s 

Guide for Advancing Health Equity provides equity-oriented 

considerations, key partners, and community examples related 

to the design and implementation of the following strategies: 

• Comprehensive Smoke-Free Policies 

• Smoke-Free Multi-Unit Housing Policies 

• Tobacco Cessation Services 

• Point-of-Sale Strategies to Address Access and Exposure to 

Tobacco Products 

The content presented is not exhaustive and is not intended 

to act as a “how-to” guide. Rather, this section is devised to 

stimulate ideas for ensuring tobacco-free living strategies are 

designed to address the needs of populations experiencing 

health inequities. Please refer to the disclaimer on page iii 

when using this Section. 

• FOSTER DIALOGUE 

ON HEALTH EQUITY 

CONCERNS WITHIN 

A COMMUNITY. 

• TRAIN STAFF AND 

PARTNERS ON EQUITY 

ISSUES SURROUNDING 

TOBACCO-FREE LIVING 

STRATEGIES. 

• IDENTIFY WAYS TO 

ADDRESS HEALTH 

EQUITY IN THE DESIGN 

AND IMPLEMENTATION 

OF STRATEGIES. 

• DEVELOP YOUR 

OWN APPROACH FOR 

ENSURING EFFORTS 

ARE ADDRESSING 

HEALTH INEQUITIES. 

USE THE CONTENT TO: 

cdc.gov/healthequityguide 34
 

 

 

 

 

 

COMPREHENSIVE SMOKE-FREE POLICIES
�

COMPREHENSIVE SMOKE-FREE POLICIES MAY INCLUDE STATE OR LOCAL LAWS OR 

REGULATIONS THAT PROHIBIT SMOKING IN ALL INDOOR AREAS OF WORKSITES AND 

PUBLIC PLACES, INCLUDING RESTAURANTS AND BARS.33,34 

MAKE THE CASE: 

Why Is This A Health Equity Issue? 

The issues below highlight the need for comprehensive 

smoke-free policies that advance health equity: 

• Differential Policy Coverage in Workplaces Employing 

Vulnerable Populations: Comprehensive smoke-free policies 

are the most effective means to fully protect all workers from 

secondhand smoke exposure in workplaces.33 In contrast, policies 

that exempt venues, such as restaurants, bars, hotels, casinos, and 

factories, may exclude many blue-collar and service sector 

workers from smoke-free protections and create disparities in 

secondhand smoke exposure.35,36 These workers—many of whom 

are racial or ethnic minorities, immigrants, and individuals with 

limited education and low incomes—may have disproportionate 

exposure to secondhand smoke in the workplace.37,38 

• Lack of Enforcement and Compliance with Existing 

Smoke-Free Policies in Some Communities: Even when a 

comprehensive smoke-free policy exists, some groups may not 

fully benefit from the policy due to inconsistent education and 

enforcement regarding the policy.35,39,40 Lack of community 

engagement or culturally appropriate efforts to inform these 

groups about policies and failure to provide these populations with 

cessation services may also influence who benefits from the policy. 

• Challenges with Adopting Comprehensive Smoke-free Policies 

in Rural Areas and Tribes: Some rural areas or tribes may be 

resistant to smoke-free policies as indicated by higher smoking 

rates in these areas.30,41 Others may be resistant because the 

economy may rely on tobacco production or use.42-44 Additionally, 

in many American Indian and Alaska Native tribes, barriers to 

such policies may arise if cultural and historical norms regarding 

ceremonial or traditional tobacco practices are not considered 

when adopting and implementing smoke-free policies.44 

Considering the cultural and social norms in communities is 

critical for the development of successful, smoke-free strategies. 

cdc.gov/healthequityguide 35
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Design and Implement with Health Equity in Mind 

To maximize health impact and advance health equity, consider these factors and others when designing, 

implementing, and evaluating comprehensive smoke-free policies: 

KEY FACTORS	� BARRIERS OR UNINTENDED OPPORTUNITIES TO MAXIMIZE IMPACT 

CONSEQUENCES 

COMMUNITY 

AWARENESS & 

INVOLVEMENT 

Engage communities 

to understand and 

shift social norms 

around smoking and 

secondhand smoke 

Some communities, particularly 

those with high rates of smoking, 

may be reluctant to implement 

comprehensive smoke-free 

policies. In other communities, 

tobacco control interventions 

may not be a priority. 

• Understand the social norms around smoking and 

secondhand smoke in underserved communities. 

• Work with organizations that serve population 

groups experiencing inequities to engage the 

community. 

• Use culturally appropriate media and education 

efforts to build awareness of the health effects of 

smoking and secondhand smoke exposure in the 

underserved communities. 

CAPACITY & 

INFRASTRUCTURE 

Build community 

capacity and 

infrastructure to 

support implementation 

of comprehensive 

smoke-free policies 

Limited capacity and infrastructure 

among agencies serving populations 

experiencing inequities may be 

a challenge to implementing 

comprehensive smoke-free policies.44 

Additionally, some of these 

organizations may receive financial 

and other supports from 

the tobacco industry.45-47 

• Prioritize inclusion of organizations serving or 

working with populations experiencing inequities 

in tobacco control coalitions. 

• Identify community leaders and train them 

to educate stakeholders about the disparities 

that result when policies are not prioritized in 

underserved communities. 

• Use partnerships to leverage resources. Explore 

funding opportunities to support organizations that 

want to join smoke-free implementation efforts. 

ACCESS TO • Incorporate free or low-cost cessation services 

CESSATION SERVICES Given existing inequities in access before and during policy implementation to help 

to and quality of health care,48 motivated individuals quit. Integrate cessation access to cessation supports 

support as part of a	� • See strategy on Tobacco Cessation Services for and services may vary.49,50 

comprehensive approach more information. 

LACK OF 

SUPPORTIVE DATA 

Identify and track 

health inequities 

Lack of timely and comprehensive 

data that fully explore health 

inequities may be a barrier to 

tobacco control efforts49 (e.g., 

data examining inequities in 

secondhand smoke exposure 

among different groups). 

• Improve collection and use of standardized data 

across population groups (e.g., geography, 

occupation, sexual orientation) to assess inequities 

in secondhand smoke exposure and policy coverage. 

• Use findings to identify where interventions are 

needed, monitor effects of an intervention, and 

track progress in addressing health inequities. 

VARIABILITY IN 

IMPLEMENTATION 

& ENFORCEMENT 

Expand smokefree policies and 

institutional practices 

State and local smoking 

restrictions may not cover all 

settings, including certain worksites 

(e.g., bars and casinos), outdoor 

public spaces (e.g., dining areas, 

construction sites), and institutions 

(e.g., mental health and substance 

abuse treatment facilities). 

• Eliminate exemptions in existing smoking restrictions. 

• Prioritize efforts in institutions with high rates of 

secondhand smoke exposure when local or state 

policies do not cover these settings. 

• Use media to address the health benefits of 

smoke-free policies and any misperceptions 

about these policies. 

• Develop appropriate enforcement mechanisms 

to support policy implementation. 

cdc.gov/healthequityguide 36
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Build the Team: Partnership for Success 

Successful efforts to implement comprehensive smoke-free policies depend on bringing a diverse set of 

partners to the table early, consistently, and authentically. These partners may include the following: 

• Area Agencies on Aging 

• Cessation support services 

• Community members 

(of diverse abilities, ages, 

cultures, gender, income 

levels, race/ethnicity, and 

sexual orientation) 

• Employee rights groups 

• Health care systems, 

hospitals, community clinics, 

and health care providers 

• Leaders and community 

champions from multiple 

sectors 

• Local businesses 

• Mental health and substance 

abuse treatment facilities 

• Organizations serving 

populations experiencing 

health inequities 

• Parks and recreation 

department 

• Public health agencies 

• School districts, universities, 

and community colleges 

• State tobacco control 

programs 

• Tobacco control groups 

• Youth, the elderly, and people 

with disabilities 

HEALTH EQUITY IN ACTION
�

Native American Tribes Adopt Tobacco Protections for Tribal Members and 

Future Generations 

Montana 

In Montana, 43% of Native American adults selfreport cigarette smoking.51 These high rates of 

commercial tobacco products use contributes to 

high rates of disease and premature death among 

Montana’s Native Americans.52 To address the 

commercial use of tobacco in their communities, 

the Blackfeet and Fort Peck tribes worked 

together to implement comprehensive smokefree indoor protections. These protections also 

safeguard casino visitors and employees from 

secondhand smoke. 

Respect for cultural traditions of tobacco use 

was instrumental in the development and 

implementation of strategies to create smoke-free 

environments. Several years earlier, the Native 

American Tobacco Coalition of Montana approached 

tribal elders to ask if they would support the creation 

of smoke-free environments. Initially, the elders 

were not supportive, because they believed this 

could potentially hinder traditional uses of tobacco, 

which are rooted in spiritual beliefs and medicinal 

practices. The elders engaged in a four-year process 

of teaching the historical and ceremonial practices 

of traditional tobacco use, including spiritual 

offerings. In turn, the coalition educated elders 

about the impact of commercial tobacco use and 

secondhand smoke exposure on tribal youth and 

future generations. 

With support from the elders, the coalition 

educated the tribal members about the distinction 

between the sacred use of tobacco and the use 

of commercial tobacco. Community engagement 

activities included commercial tobacco-free 

celebrations, health fairs, youth-focused events, 

and trainings. By conducting extensive educational 

initiatives for tribal members and elders, the 

Blackfeet and Fort Peck Tribal Nations were able 

to create smoke-free indoor environments that 

included casinos. As a result, other tribes have 

created smoke-free environments in most tribal 

facilities. The coalition learned a valuable lesson: to 

be successful, smoke-free strategies need to be true 

to the people and rooted in cultural tradition. 

cdc.gov/healthequityguide 37
 

HEALTH EQUITY IN ACTION
�

Smokefree table tent at Birmingham, AL restaurant. Photo courtesy of the JCDH and the HAP. 

Partnerships and Educational Initiatives Lead to Smoke-Free Air Protections 

Birmingham, AL 

Jefferson County Department of Health (JCDH) 

and the Health Action Partnership (HAP) are 

helping to implement smoke-free protections in 

Birmingham—impacting approximately 356,000 

Jefferson County residents and commuters. 

With support from CDC’s Communities Putting 

Prevention to Work program, the health 

department conducted community needs 

assessments and used geographic information 

systems (GIS) mapping to track rates of smoking, 

heart attack, and cancer to identify communities 

with the highest need for smoke-free protections. 

Then they overlaid those maps with maps of lowincome areas. 

After identifying high-need communities, JCDH 

and HAP conducted evaluation interviews in 

these areas to assess the key organizations and 

community champions that could become a 

conduit for educating residents on secondhand 

smoke issues. Working with a variety of local 

organizations, faith-based leaders, and the 

media, the community was able to successfully 

educate and increase community awareness 

about the benefits of smoke-free environments. 

The Friends of West End, a local organization 

with strong ties to the targeted communities, 

educated nearly 100 neighborhood association 

presidents. The presidents then educated their 

respective communities while local pastors 

did the same among their congregations. 

JCDH’s understanding of culturally appropriate 

educational media led to a well-received 

radio soap opera, Live Well Camberwell. The 

educational radio program and health expert 

interviews were aired on stations with largely 

African American audiences. 

All of these educational initiatives contributed to 

increasing awareness around the health effects 

of secondhand smoke exposure in indoor places 

of employment including restaurants, bars, and 

hotels. When smoke-free protections were put in 

place, the HAP provided technical assistance to 

ensure proper implementation of and compliance 

with the smoke-free protections. 

cdc.gov/healthequityguide 38
 

 

SMOKE-FREE MULTI-UNIT HOUSING POLICIES 

SMOKE-FREE MULTI-UNIT HOUSING POLICIES AIM TO PROTECT NONSMOKERS WHO 

LIVE IN, WORK, AND VISIT MULTI-UNIT RESIDENCES SUCH AS APARTMENTS, 

CONDOMINIUMS, TOWNHOUSES, DUPLEXES, AND AFFORDABLE HOUSING COMPLEXES 

FROM SECONDHAND SMOKE. 

MAKE THE CASE: 

Why Is This A Health Equity Issue? 

The issues below highlight the need for smoke-free multiunit housing policies that advance health equity: 

• Increased Secondhand Smoke Risks among Vulnerable 

Populations: Low-income individuals generally have 

higher smoking rates,30 which may result in increased 

exposure to secondhand smoke in affordable and public 

housing. Given that many residents living in these 

settings are vulnerable population groups (e.g., children, 

older adults, racial/ethnic minorities, and those with a 

disability),53 secondhand smoke exposure is critical to 

address. For instance, many racial/ethnic minorities 

and low-income populations suffer higher rates of 

asthma and other tobacco-related health issues,54 

making them particularly vulnerable to the effects 

of secondhand smoke exposure. Children are 

also vulnerable to developing health effects from 

secondhand smoke exposure.55 

• Residents Who are Being Exposed to Secondhand 

Smoke May Have Limited Alternative Housing Options: 

Even when residents of multi-unit housing do not allow 

smoking in their unit, secondhand smoke can enter their 

unit from other units or common areas through shared 

ventilation systems, air spaces, 

windows, and hallways, putting residents at risk.54,56,57

Low-income residents in affordable or public housing 

complexes who are being involuntarily exposed to 

secondhand smoke in their homes in this manner 

may have limited alternative housing options or be 

unable to move. 

cdc.gov/healthequityguide 39
 

 

 

 

 

 

 

 

 

 

 

 

 

 

Design and Implement with Health Equity in Mind 

To maximize health impact and advance health equity, consider these factors and others when designing, 

implementing, and evaluating smoke-free multi-unit housing policies: 

KEY FACTORS	� BARRIERS OR UNINTENDED OPPORTUNITIES TO MAXIMIZE IMPACT 

CONSEQUENCES 

MISPERCEPTIONS 

Clarify intent and 

address misperceptions 

about smoke-free 

multi-unit housing 

strategies 

Organizations that work on behalf 

of low-income residents (e.g., 

residents’ rights organizations, 

affordable housing groups) may 

have misconceptions about the 

intent or effects of smoke-free 

multi-unit housing strategies. 

• Ensure residents and owners understand that the 

smoke-free policy is designed to promote a healthy 

home environment and reduce secondhand smoke 

exposure—not to remove smokers or prevent new 

smokers from moving in, as long as they comply 

with the policy. 

• Consider working across different types of multi-unit 

housing (e.g., public, affordable, and market-rate) 

to show everyone deserves clean air and prevent 

concerns about discrimination. 

STAKEHOLDER 

SUPPORT 

Address concerns and 

build support among 

housing providers 

If landlords are unaware of 

resident support for smoke-free 

policies, they may have concerns 

that such a policy will lead to 

reduced occupancy or will be 

difficult to enforce. 

• Alleviate concerns of stakeholders (e.g., landlords, 

apartment owners) by educating them on the 

business, health, and safety benefits of 

smoke-free policies. 

• Provide tools and training on how to gather resident 

feedback, navigate the implementation process, 

develop monitoring mechanisms, and address 

noncompliance. 

COMMUNITY 

INVOLVEMENT 

& AWARENESS 

Engage residents in 

strategy development 

and implementation 

Strategies developed without 

resident input may negatively 

affect strategy implementation 

and enforcement. 

• Identify residents to serve as champions and 

involve them throughout the development and 

implementation process. 

• Gather input through resident surveys and forums, 

and collaborate with resident associations to 

develop the strategy. 

• Establish mechanisms to ensure that residents are 

aware of the policy and its benefits (e.g., culturally 

appropriate education initiatives, resident forums). 

ACCESS 

Increase access to 

free or low-cost 

cessation services 

Residents without access to 

cessation supports may not 

comply with smoke-free policies, 

placing other residents at risk for 

secondhand smoke exposure. 

• Provide smokers with free access to evidence-based 

cessation treatments to ease the transition to a 

smoke-free environment, increase compliance, prevent 

smokers from feeling stigmatized, and help them quit 

smoking, thus maximizing the policy’s health benefits. 

• Offer and promote cessation services in or near the 

complex at convenient times before and during policy 

implementation. 

EQUITABLE 

IMPLEMENTATION 

Anticipate additional 

challenges to policy 

implementation 

After policy implementation, 

smokers may tend to congregate 

in outdoor areas near buildings, 

exposing residents in outdoor 

or adjacent indoor areas to 

secondhand smoke, which may 

enter the building through doors, 

windows, or vents. 

• Make the entire property smoke-free or restrict 

smoking to a few designated outdoor areas located 

far enough away from entrances and exits to prevent 

secondhand smoke from infiltrating indoor areas. 

• Improve compliance by conducting tailored resident 

engagement, education, and cessation efforts. 

• In supportive housing settings, (e.g., homeless shelters, 

mental health and substance abuse treatment 

facilities), work with staff to find tailored, contextspecific approaches. 

cdc.gov/healthequityguide 40
 

 

 

 

 

 

 

 

 

 

 

 

 

 

Build the Team: Partnership for Success 

Successful efforts to implement smoke-free multi-unit housing policies depend on bringing a diverse set of 

partners to the table early, consistently, and authentically. These partners may include the following: 

• Area Agencies on Aging • Low-income residents 

• Cessation support services • Organizations serving populations 

experiencing health inequities • Community members (of diverse abilities, ages,

cultures, gender, income levels, race/ethnicity, • Real estate developers 

and sexual orientation) • Residential property owners, 

• Condominium owners management companies 

• Faith-based organizations • State tobacco control programs 

• Housing industry organizations, local housing • Residents’ rights/fair housing organizations 

authorities, and nonprofit housing associations • Youth, the elderly, and people with disabilities 

• Immigrants and refugees 

HEALTH EQUITY IN ACTION 

Creating Healthy Environments through Smoke-Free Multi-Unit Housing Policies
�

San Antonio, TX 

Everyone has the right to breathe clean air, 

especially in their own home. Yet in many San 

Antonio multi-unit housing complexes, residents 

were being exposed to secondhand smoke 

infiltrating their units from neighboring units. To 

address this issue, the San Antonio Metropolitan 

Health District (SAMHD) worked with the San 

Antonio Housing Authority (SAHA) to implement 

a smoke-free multi-unit housing policy for all 70 

of its housing sites. These efforts were made 

possible with support from a combination of 

state and local funds. 

SAMHD focused on making multi-unit housing 

smoke-free with a strategy that covered all indoor 

areas, since a comprehensive policy would have 

a greater impact on health equity for all SAHA 

residents and staff. Both organizations recognized 

the importance of community engagement to 

ensure policy success. They worked closely with 

residents and staff in mini-community centers 

associated with each housing campus. Engaging 

the residents through the community centers— 

a resource that residents were already turning 

to for information—was key to the success of 

this approach. 

SAMHD bolstered its outreach and education 

efforts through a partnership with the American 

Cancer Society (ACS). ACS educated community 

center staff on how to answer questions about the 

new policy, to refer residents to the state quitline, 

and to discuss options for obtaining nicotine 

replacement therapy (e.g. nicotine patches). 

All materials were printed in both English and 

Spanish, and staff in many centers were able 

to communicate the benefit of smoke-free air 

protections to residents in their own language. 

ACS and SAHA also helped organize town hall 

meetings to educate residents and discuss the 

benefits of smoke-free protections in an open 

forum. As a result of the policy, nearly 16,000 

residents (many of them low-income immigrants 

and racial/ethnic minorities) now have access to 

cleaner air in their homes. 

cdc.gov/healthequityguide 41
HEALTH EQUITY IN ACTION
�

Housing Authority and Public Health Commission Partner on Smoke-Free Housing 

Boston, MA 

Building relationships with the Boston Housing 

Authority, other city agencies, and community-based 

organizations, the Boston Public Health Commission 

(BPHC), with support from the CDC’s Communities 

Putting Prevention to Work program, educated 

housing providers about the voluntary adoption 

of smoke-free multi-unit housing policies. The 

Commission has also successfully leveraged support 

for smoke-free housing among residents in all market 

sectors (e.g., market rate, public housing), as well as 

used data to identify disparities in health outcomes 

across residents of different types of housing. The 

goal is to ensure that residents, particularly those 

most vulnerable to secondhand smoke exposure, 

have clean air to breathe in their homes. Smoke-free 

protections in public housing, affordable housing, and 

market-rate housing have the potential to provide 

protection for populations with high exposure to 

secondhand smoke, including low-income families, 

children with asthma, immigrants, elderly residents, 

and persons with chronic diseases or disabilities. 

The BPHC has taken a series of steps to increase 

smoke-free protections in and around multi-unit 

housing complexes. One key to the success of the 

BPHC’s policy was its approach of working closely 

with stakeholders such as the Boston Housing 

Authority and landlords, property management 

companies, and community development 

corporations. Input from residents in policy 

development was critical, and mini-grants to 

community development corporations supported 

community engagement. The BPHC also worked 

strategically with a variety of community partners 

to make the case to landlords and housing agencies 

that a majority of residents wanted smoke-free 

housing, and that going smoke-free would benefit 

all stakeholders. The BPHC provided technical 

assistance in developing and implementing a smokefree multi-unit housing policy. Because Massachusetts 

has relatively good coverage of smoking cessation 

treatments, many smokers in the state can access 

affordable cessation services. 

The BPHC approach led to some notable early 

successes. The Boston Housing Authority portfolio 

became 100% smoke-free in September 2012, assuring 

a healthier environment for the 23,000 residents 

living in their 12,000 units. Community development 

corporations have transitioned over 600 units to 

smoke-free status, and continue to bring additional 

units on line as smoke-free. There are now 6,600 nonpublic smoke-free units and the BPHC sees this as 

just the beginning. As Margaret Reid, Director of the 

Division of Healthy Homes and Community Supports 

at the BPHC, says, “We are supporting smoke-free 

policies and awareness so that smoke-free becomes 

the norm in Boston multi-unit housing, whether it is 

public, subsidized, or market-rate.” 

cdc.gov/healthequityguide 42
 

 

 

 

TOBACCO CESSATION SERVICES 

TOBACCO CESSATION STRATEGIES HELP PEOPLE QUIT SMOKING OR USING OTHER FORMS 

OF TOBACCO. THESE STRATEGIES MAY INCLUDE CLINICAL SCREENING AND REFERRAL 

SYSTEMS, QUIT LINES, BEHAVIORAL COUNSELING, AND CESSATION MEDICATIONS.58 

MAKE THE CASE: 

Why Is This A Health Equity Issue? 

The issues below highlight the need for tobacco cessation strategies 

that advance health equity: 

• Varying Rates of Smoking and Cessation among Different 

Communities: In the United States, certain population groups stand 

out as having higher-than-average smoking rates, lower-than-average 

cessation rates, or higher-than-average rates of tobacco-related 

diseases.49,59,60 For example, population groups with disproportionately 

high rates of smoking include American Indian and Alaska Natives,7,60 the 

lesbian, gay, bisexual, and transgender (LGBT) communities,61-63 people 

with mental illness64 and substance abuse conditions,7

 and people with 

disabilities.65 African American adults have been found to be more likely 

to express interest in quitting and more likely to have tried to quit in the 

past year than white adults, but are less likely to use proven treatments 

(e.g., counseling and/or medications) and are less likely to succeed in 

quitting.59 Adults aged 65 or older have also been found to be less 

likely to attempt smoking cessation compared to younger adults.59,66

Additionally, low-income populations are more likely to smoke, less 

likely to quit, and often lack access to affordable cessation support.49,60,67 

• Barriers to Accessing Cessation Resources: Differential access and 

quality of health care may present barriers to quitting.50 For example, 

uninsured smokers may be less likely to receive quitting advice or other 

forms of cessation treatment from health care providers.50 Additionally, 

certain population groups, including African Americans and Hispanics, 

are less likely to be screened for tobacco use or receive smoking 

cessation interventions.59,68-70 

• Challenges to the Widespread Use of Evidence-Based Cessation 

Interventions: There is limited research on effective approaches 

for promoting and increasing utilization of cessation interventions 

among population groups experiencing health disparities.71,72 A lack of 

sensitivity to social norms and cultural traditions in developing cessation 

interventions may influence intervention use and ultimate effectiveness. 

cdc.gov/healthequityguide 43
 

 

 

 

 

 

 

 

 

 

 

Design and Implement with Health Equity in Mind 

To maximize health impact and advance health equity, consider these factors and others when designing, 

implementing, and evaluating tobacco cessation strategies: 

KEY FACTORS	� BARRIERS OR UNINTENDED OPPORTUNITIES TO MAXIMIZE IMPACT 

CONSEQUENCES 

ACCESS 

Increase access to 

cessation services 

by integrating them 

into health systems 

and making them 

convenient 

Certain population groups are 

less likely to be screened for 

tobacco use or receive tobacco 

cessation counseling.69,70 

Additionally, cessation services 

may be underused because of 

limited knowledge, awareness, 

and cultural beliefs.73,74 

• Prioritize integration of tobacco screening and 

provision of/referral for evidence-based cessation 

treatments into institutions that are already 

serving vulnerable populations (e.g., community 

health centers, Federally Qualified Health Centers, 

rural health clinics, mental health and substance 

abuse treatment facilities). 

• Prioritize the promotion of existing cessation 

services including tobacco quitlines and 

Web sites to populations experiencing health 

disparities. 

• Integrate cessation programs and support into 

community institutions located in places where 

people already go (e.g., public housing, faithbased settings, social service agencies). 

• Train community health outreach workers to 

provide cessation services during home visits. 

COST 

Remove/reduce 

cost and insurance 

barriers 

Costs associated with cessation 

services, which may result from 

lack of/inadequate health 

insurance coverage pose 

particularly significant barriers 

for low-income populations.75-77 

• Develop relationships with private and public 

health insurers and health care systems, including 

state Medicaid programs, to expand insurance 

coverage of cessation services. 

• Consider ways to eliminate or minimize cost and 

other barriers (e.g., co-pays, prior authorization 

requirements) to accessing cessation treatments. 

DIVERSE NORMS 

AND CUSTOMS 

Ensure that 

cessation services 

are culturally relevant 

and appropriate 

Limited research on effective 

approaches to promote cessation 

services interventions across 

different groups may hinder the 

utilization of such interventions.49,71,78

For example, tobacco quitlines may 

be accessed less by groups with 

cultural norms that avoid seeking 

counseling from strangers. 

• Evaluate the effectiveness of cessation 

interventions across different population groups. 

• Ensure that underserved populations have 

access to and are aware of cessation services 

(e.g., promote services through culturally 

appropriate communication channels). 

• If such populations are still not using, or are 

unsatisfied with, existing cessation services, 

partner with relevant organizations to increase 

culturally relevant training of providers or to tailor 

these services to meet the populations’ needs. 

cdc.gov/healthequityguide 44
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Build the Team: Partnership for Success 

Successful efforts to implement tobacco cessation strategies depend on bringing a diverse set of partners 

to the table early, consistently, and authentically. These partners may include the following: 

• Academic institutions • Employers • National culturally specific 

• Cessation support services • Health care systems cessation guidance 

• Community-based organizations 

• Community health centers, 

including Federally Qualified 

• Health insurers 

• Lay health providers/ 

promotoras 

organizations 

• Public health agencies 

• State quitline providers 

Health Centers and rural health • Leaders and community • State tobacco control programs 

clinics champions from multiple sectors • Tobacco control groups 

• Community members (of • Media • Workplace wellness 

diverse abilities, ages, cultures, 

gender, income levels, race/ 

ethnicity, and sexual orientation) 

• Mental health and substance 

abuse treatment facilities 

organizations 

HEALTH EQUITY IN ACTION
�

Expanding Cessation Services in Marginalized Communities 

St. Louis, MO 

With the goal of reducing tobacco-related health 

disparities, the St. Louis County Department of Health 

(DOH), with support from CDC’s Communities Putting 

Prevention to Work program, set out to increase 

access to cessation services among populations with 

high smoking rates. “Being in their neighborhood and 

speaking their language” was a critical strategy for 

helping people most in need of cessation resources, 

noted Barry Freedman, Project Manager for the 

Communities Putting Prevention to Work program at the 

DOH. DOH partnered with three trusted organizations 

that had strong ties in the community to provide free 

and low-cost services and culturally competent care. 

Each partnership is briefly described below. 

Casa de Salud, a local health clinic, provides cessation 

services to low-income and limited-English-speaking 

Hispanic populations, including onsite one-on-one 

cessation counseling and nicotine replacement therapy 

(NRT), such as nicotine patches. All of this is done using 

culturally appropriate materials in an environment where 

clients can feel safe. 

SAGE Metro St. Louis works with the lesbian, gay, 

bisexual, and transgender (LGBT) communities and 

offers cessation counseling services and NRT free of 

charge. SAGE also provides education on the 

techniques the tobacco industry has used to target 

LGBT communities. Having a presence at the city’s 

three major gay pride events proved an effective 

outreach and education approach. 

The St. Louis Christian Chinese Community Service 

Center worked to provide cessation services, including 

individual counseling, support, and other resources, 

to Asian-American restaurant employees with high 

rates of smoking. Because of limited health literacy 

in the communities they serve, the Center conducted 

traditional Chinese puppet shows to encourage cessation 

and provided health information to over 500 Chinese 

Americans. The shows are especially powerful because 

they respect Chinese cultural norms while conveying 

important health messages to multiple generations. 

In addition to these partnerships, the DOH is helping 

support low-income and uninsured community clinic 

clients. DOH is training providers in those clinics to 

facilitate a free cessation program, and is offering a free 

three-month supply of NRT products to smokers who 

want to quit. 

cdc.gov/healthequityguide 45
 

HEALTH EQUITY IN ACTION
�

Using Partnerships to Increase Access 

to Cessation Services 

Santa Clara County, CA 

“A one-stop shop [is] more likely to work than having 

people go to different places for [tobacco cessation] 

services,” noted Kris Vantornhout, Program Manager 

for the Communities Putting Prevention to Work 

program at the Santa Clara County Public Health 

Department (SCCPHD). With this in mind, Santa Clara 

County’s Tobacco Prevention Program strategically 

partnered with established community-based 

organizations (CBOs) throughout the county. These 

CBOs were poised to implement cessation services 

in neighborhoods with high numbers of smokers. 

At times, securing diverse community leadership 

involvement was challenging, but focused efforts 

were successful in finding champions to lead the way. 

SCCPHD awarded twenty-seven mini-grants to 

CBOs to expand cessation counseling, referrals, and 

access to nicotine replacement therapy (NRT). These 

grants supported organizations working with the 

Vietnamese, African American, Latino, and Lesbian, 

Gay, Bisexual, and Transgender (LGBT) communities, 

and engaged diverse partners. Efforts also focused 

on improving cessation services and referral systems 

in mental health facilities, health care clinics, and 

college campuses. 

CBOs integrated cessation services into organizational 

practice by implementing the “ask, advise, refer” 

model during intake processes and, as appropriate, 

referring patients or students to trained staff for 

cessation assistance. Providing culturally and 

linguistically relevant messaging around secondhand 

smoke exposure was also important for increasing the 

uptake of cessation services. Tobacco-free messaging 

and cessation information were shared onsite, as well 

as at outreach events such as the San Jose LGBT 

Pride Celebration, the annual Martin Luther King 

Luncheon, and the Holiday Fair. 

As a result of the Tobacco Prevention Program’s 

partnership efforts, cessation services are now 

available to some of the most vulnerable populations 

Smoke-free sign on medical center campus in Santa Clara 

County, CA. Photo courtesy of Breathe California. 

in the county. Thirty health facilities, 8 colleges, 

and 11 CBOs now have staff or clinicians using 

the “ask, advise, refer” model to reach over 

544,000 residents. Approximately 8,000 units 

of NRT were distributed through these networks 

within less than two years, and post-intervention 

surveys have shown an overall 39% quit success 

rate, with an amazing 50% quit rate within the 

Vietnamese community. 

cdc.gov/healthequityguide 46
 

 

 

 

POINT-OF-SALE STRATEGIES TO ADDRESS ACCESS AND 

EXPOSURE TO TOBACCO PRODUCTS 

POINT-OF-SALE (POS) STRATEGIES TO REDUCE THE AVAILABILITY AND APPEAL OF TOBACCO PRODUCTS 

MAY INCLUDE ADDRESSING THE MARKETING AND AFFORDABILITY OF THESE PRODUCTS THROUGH 

RESTRICTIONS ON THE POINT-OF-SALE TOBACCO ADVERTISING, PROMOTION (INCLUDING PRICE 

PROMOTIONS), DISPLAYS, AND PLACEMENT; THE SALES OF SPECIFIC TYPES OF TOBACCO PRODUCTS 

(E.G., FLAVORED PRODUCTS); AND TOBACCO RETAILER LOCATION AND DENSITY.79-81,* 

MAKE THE CASE: 

Why Is This A Health Equity Issue? 

The issues below highlight the need for POS strategies that advance health equity: 

• Different Exposure to POS Advertising and Targeted Marketing: Studies 

have consistently shown that low-income communities82 and communities 

of color are more heavily exposed to POS tobacco advertising than other 

communities.83,84 Additionally, such advertising may be targeted to or 

disproportionately impact certain population groups. For instance, the 

messaging used in marketing menthol cigarettes has been culturally tailored 

and targeted toward communities of color, especially Africans Americans.85 

• Placement of and Price Discounts on Tobacco Products: Tobacco 

companies have used a variety of point-of-sale strategies to place tobacco 

products prominently in the retail environment and keep these products 

affordable.86 For example, in 2011, the tobacco industry spent an estimated 

$8 billion, or nearly $23 million per day, on cigarette advertising and 

promotional expenses in the United States alone. Approximately 84% (or 

nearly $7 billion) of this expenditure was spent on price discounts to cigarette 

retailers or wholesalers to reduce the price of cigarettes to consumers.87 

A placement strategy may include placing tobacco products (e.g., cigarillos, 

cigars) next to candy or within the view of children and youth.88 Additionally, 

tobacco companies may deeply discount their products in stores in lowerincome communities and require targeted placement of signs advertising 

lower prices in these stores.89 Youth and low-income individuals may be 

particularly sensitive to prominently placed, inexpensive tobacco products.79,90

• Greater Density of Tobacco Retailers in Underserved Communities: 

Research has shown that tobacco retail outlets are more heavily concentrated
�

in low-income communities and communities of color than in higher income
�

communities.91-94 This makes tobacco products more readily accessible,
�

potentially increasing consumption.94
�

*

Note: The Tobacco Control Act preserves the authority of state, local, and tribal governments to 

regulate tobacco products in certain specific respects. It also prohibits, with certain exceptions, state 

and local requirements that are different from, or in addition to, requirements under the provisions of 

the FDCA relating to specified areas. 

cdc.gov/healthequityguide 47
 

 

 

 

 

 

 

 

 

 

Design and Implement with Health Equity in Mind 

To maximize health impact and advance health equity, consider these factors and others when designing, 

implementing, and evaluating POS strategies: 

KEY FACTORS	� BARRIERS OR UNINTENDED OPPORTUNITIES TO MAXIMIZE IMPACT 

CONSEQUENCES 

RESOURCE 

& FUNDING 

LIMITATIONS 

Prioritize and 

prepare resources 

for communities in 

greatest need 

Underserved communities 

may have fewer resources to 

implement POS strategies. 

Additionally, such communities 

may have other priorities that 

make it difficult to implement 

tobacco control initiatives. 

• Conduct assessments to examine tobacco retail 

density, the amount of POS advertising, and 

tobacco-related health disparities. 

• Prioritize intervention efforts to address areas 

with greatest need. 

• Engage partners who can provide technical 

assistance to identify viable POS strategies and 

overcome barriers. 

• Participate in community coalitions and events in 

order to understand community priorities, align 

POS efforts with those priorities, and educate and 

mobilize the community around these efforts. 

ECONOMIC 

STABILITY 

Support retailers 

when implementing 

POS strategies 

Underserved communities, 

which can have disproportionately 

high concentrations of tobacco 

retailers, may oppose POS 

strategies due to concerns about 

the potential financial effects on 

local businesses. 

• Find creative mechanisms to support retailers 

that are implementing POS strategies. 

• Establish programs that may help retailers 

transition from relying on sales of tobacco product 

to selling healthier products (e.g., Healthy Food 

Financing,95 healthy corner store initiatives96). 

COMMUNITY 

AWARENESS 

Build community 

awareness and skills 

to counter tobacco 

advertising 

Tobacco product displays and POS 

advertising may distort perceptions 

of the pervasiveness of tobacco 

use among adolescents,97 increase 

the likelihood of youth smoking 

initiation,97,98 and may prompt 

impulse buys (e.g., among smokers 

who are trying to quit).99 

• Increase community awareness of industry 

marketing tactics to help people critically assess 

the advertising they see around them. 

• Work with media outlets serving specific 

population groups to reinforce positive 

messaging and to counter any negative effects 

of tobacco marketing. 

VARIABLE 

IMPLEMENTATION 

& ENFORCEMENT 

Support Implementation 

and Enforcement of POS 

Strategies, particularly 

in communities with 

tobacco-related 

inequities. 

• Consider developing implementation plans Disparities may increase if to support consistent and equitable policy POS strategies are not fully compliance. implemented or enforced in 

communities with high • Consider establishing processes for accountability 

smoking rates or social norms and gathering feedback from all communities 

that support tobacco use. affected by the policy. 

cdc.gov/healthequityguide 48
 

 

 

 

 

 

 

 

 

 

 

 

 

Build the Team: Partnership for Success 

Successful efforts to implement POS strategies in communities with tobacco-related disparities depend 

on bringing a diverse set of partners to the table early, consistently, and authentically. These partners may 

include the following: 

• Community members (of diverse abilities, ages, • School districts, universities, and 

cultures, gender, income levels, race/ethnicity, community colleges 

and sexual orientation) • Senior Centers 

• Healthy food retail groups • State tobacco control programs 

• Leaders and community champions from • Tobacco control groups (including groups multiple sectors representing populations experiencing health 

• Local governments disparities) 

• Local store owners • Youth volunteers/coalitions 

• Public health agencies • Zoning and Planning organizations 

• Public Works Department 

HEALTH EQUITY IN ACTION
�

Citywide Restrictions Tackle Flavored Tobacco Products
�

New York, NY 

“The price point for entry into the world of 

tobacco is one dollar.” Kevin Schroth, Senior Legal 

Counsel for Policy, at New York City’s (NYC) 

Department of Health and Mental Hygiene was 

describing sales of single, flavored cigarillos and 

little cigars. These inexpensive alternatives to 

cigarettes are heavily marketed in stores in lowincome and minority urban neighborhoods. These 

products are often flavored, come in brightly 

colored packages, and are prominently placed in 

stores next to gum and candy—all features that 

make them appealing to children and youth. 

“Kids spend twice as much time in convenience 

stores as adults,” said Schroth. “It’s not a 

coincidence that these flavored tobacco products 

look similar to other products marketed to kids.” 

The point-of-sale marketing of these products 

contribute to perceptions among youth that these 

products are easily accessible and that their use is 

acceptable and cool. 

The health department partnered with the New 

York City Coalition for a Smoke-Free City and 

community-based organizations such as Korean 

Community Services, which serves an Asian 

population with high smoking rates. Together, 

with support from state and city funds, they 

educated community stakeholders about the 

health risks associated with flavored noncigarette tobacco products. In 2009, the NYC 

City Council passed a law that restricted the sale 

of flavored non-cigarette tobacco products, with 

the exception of menthol, mint, wintergreen, and 

tobacco-flavored products, in stores throughout 

the city, with the exception of tobacco bars. The 

strategy is part of a comprehensive approach to 

protect all residents, especially impressionable 

youth, in all New York City communities from 

tobacco industry marketing. The example has 

motivated other local jurisdictions, such as 

nearby Providence, Rhode Island, to implement 

similar measures. 

cdc.gov/healthequityguide 49
 

 

 

HEALTH EQUITY IN ACTION
�

Tobacco-Free Pharmacies Promote Health for All
�

San Francisco, CA 

Many people go to pharmacies to purchase 

medications and other items to improve their health. 

Why then do many major pharmacy chains and 

independent pharmacies sell tobacco products which 

contribute to severe health effects? The California 

LGBT Tobacco Education Partnership (the Partnership) 

saw this discrepancy as an opportunity to decrease 

the widespread availability of tobacco products. 

With the high rates of smoking within the LGBT 

population, the Castro District (historically considered 

the center of San Francisco’s LGBT communities) 

was the Partnership’s priority location in its attempt 

to eliminate tobacco sales in pharmacies. The 

Partnership strategically engaged independent 

pharmacies that were already tobacco-free, 

acknowledging them with certificates. These 

pharmacies also educated community stakeholders on 

the benefits of tobacco-free pharmacies. In addition, 

a public opinion survey of smokers and nonsmokers 

assessed the need for tobacco-free pharmacies. 

To ensure that every San Francisco resident, not 

only those living in the Castro District, has access 

to tobacco-free pharmacies, the Partnership, with 

support from the California Department 

of Public Health, Tobacco Control 

Program and others, implemented a 

citywide strategy. Working with diverse 

partners, including the San Francisco 

Tobacco-Free Coalition, the University of California 

at San Francisco School of Pharmacy, and the Board 

of Supervisors, the Partnership made a compelling 

research-supported argument that pharmacies should 

be hubs for health, and that this role was inconsistent 

with selling tobacco products. Even in the face of 

opposition from some local media outlets and national 

retailers, the Partnership remained focused on the 

message that health for all should be the priority. 

On October 1, 2008, San Francisco became the 

first city in the United States to eliminate the sale 

of tobacco products in its pharmacies (through 

changes to the Health Code), affecting an estimated 

100 pharmacies and all 805,000 city residents. The 

policy’s success has inspired similar efforts in cities 

from nearby Richmond, CA to Boston, MA. As Bob 

Gordon of the Partnership stated, the policy has 

“changed a social norm around the availability and 

accessibility of tobacco products in San Francisco. 

That alone is an amazing outcome.” 

cdc.gov/healthequityguide 50
’ 

 

 

 

 

 

 

 

 

 

SECTION 3 Maximizing Healthy Food and Beverage 

Strategies to Advance Health Equity 

USE THE CONTENT TO: 

• FOSTER DIALOGUE 

ON HEALTH EQUITY 

CONCERNS WITHIN 

A COMMUNITY. 

• TRAIN STAFF AND 

PARTNERS ON EQUITY 

ISSUES SURROUNDING 

TOBACCO-FREE LIVING 

STRATEGIES. 

• IDENTIFY WAYS TO 

ADDRESS HEALTH 

EQUITY IN THE DESIGN 

AND IMPLEMENTATION 

OF STRATEGIES. 

• DEVELOP YOUR 

OWN APPROACH FOR 

ENSURING EFFORTS 

ARE ADDRESSING 

HEALTH INEQUITIES. 

Rural areas, low-income communities, and communities of 

color are most affected by limited access to healthful food 

and beverages. Limited access to healthful foods makes 

it particularly difficult to make healthy choices in these 

environments.100 Addressing inequities in healthy food and 

beverage environments may help address many chronic 

disease health disparities. 

The Healthy Food and Beverage section of A Practitioner s 

Guide for Advancing Health Equity provides equity-oriented 

considerations, key partners, and community examples related 

to the design and implementation of the following strategies: 

• Community Food Retail Environment 

• Healthy Restaurants and Catering Trucks 

• Healthy Food in School, Afterschool, and Early Care 

and Education Environments 

• Food Access through Land Use Planning and Policies 

• Breastfeeding Practices and Policies 

The content presented is not exhaustive and is not intended 

to act as a “how-to” guide. Rather, this section is meant 

to stimulate ideas for ensuring healthy food and beverage 

strategies are designed to address the needs of populations 

experiencing health inequities. Refer to the disclaimer on 

page iii when using this Section. 

cdc.gov/healthequityguide 51
 

 

 

 

COMMUNITY FOOD RETAIL ENVIRONMENT
�

COMMUNITY FOOD RETAIL STRATEGIES CAN INCREASE ACCESS TO HEALTHY FOOD OR 

DECREASE ACCESS TO UNHEALTHY FOODS IN LOCAL STORES, SUPERMARKETS, FARMERS’ 

MARKETS, AND OTHER FOOD RETAIL OUTLETS. SUCH STRATEGIES MAY INCLUDE 

DEVELOPING FULL-SERVICE GROCERY STORES, IMPROVING OFFERINGS IN SMALL STORES, 

AND STARTING OR EXPANDING FARMERS’ MARKETS. 

MAKE THE CASE: 

Why Is This A Health Equity Issue? 

The issues below highlight the need for community food 

retail strategies that advance health equity: 

• Limited Access to Healthy Food in Underserved 

Communities: Differences in geographic food 

access have been documented in several national 

studies.100,101 For example, low-income communities, 

communities of color, and rural areas have been 

found to have fewer supermarkets than wealthier 

communities, predominantly white neighborhoods, 

and urban areas.102,103 

• Additional Barriers Exist for Many Underserved 

Communities in Accessing Healthy Food: Barriers to 

accessing healthy foods may include dependence on 

public transit, difficulty transporting groceries due to 

lack of reliable transportation,100 and lack of access to 

healthy options that reflect cultural food preferences. 

Additionally, higher costs of healthy foods,100,104-106 and 

low-quality food selection in some communities,107,108 

may serve as barriers. 

• Improving Access to Healthful Food Can Provide 

Opportunities for Economic Development in 

Underserved Communities: Strategies that increase 

access to healthy food in underserved communities can 

have positive effects beyond improved nutrition. Such 

strategies may create jobs, revitalize commercial areas, 

and provide tax revenues. For example, grocery stores 

may act as anchors for retail developments, spurring 

local economic development.100 

cdc.gov/healthequityguide 52
 

 

 

 

 

 

 

 

 

Design and Implement with Health Equity in Mind 

To maximize health impact and advance health equity, consider these factors and others when designing, 

implementing, and evaluating community food retail strategies: 

KEY FACTORS	� BARRIERS OR UNINTENDED OPPORTUNITIES TO MAXIMIZE IMPACT 

CONSEQUENCES 

COMMUNITY 

AWARENESS & 

INVOLVEMENT 

Ensure community 

engagement in and 

awareness of healthy 

food retail projects 

Decisions about food availability 

may not reflect the needs and 

desires of community residents 

including perceptions of what is 

culturally appropriate. 

• Engage populations experiencing health inequities 

in community food assessments, GIS mapping, 

and other efforts to assess food access. 

• Ensure those selected for food policy councils 

and other food initiatives designed to improve the 

food environment have an understanding and the 

capacity to address health disparities affecting 

certain population groups. 

• Increase residents’ awareness of new healthy food 

retailers, incentives for purchasing healthy foods 

(e.g. Double Up Food Bucks program109), and 

healthy food preparation. 

AFFORDABILITY 

Ensure affordable 

pricing for healthy 

food options and 

increase low-income 

residents’ purchasing 

power 

Low-income communities and 

communities of color may have 

higher food prices for healthy 

food than high-income and white 

communities.105,108,110,111 Additionally, 

healthy food retailers may not 

accept SNAP and WIC as forms 

of payment. 

• Promote the use of food assistance programs 

(e.g., Supplemental Nutrition Assistance Program 

(SNAP) and the Women, Infant, and Children’s 

Program (WIC)) at healthy food retailers.112 

• Lower retail costs by supporting efforts that 

encourage lower prices (e.g., streamlining 

distribution, facilitating bulk purchasing by 

multiple stores).112,113 

• Provide support to increase demand of healthy 

options (e.g., assist with marketing and displaying 

food) and reduce food waste due to spoilage (e.g., 

offer ways to store and refrigerate foods).112,113 

• Increase SNAP participant purchasing power by 

providing incentives for the purchase of healthy 

food (e.g., Double Up Food Bucks program109). 

NEGATIVE 

PERCEPTIONS & 

LIMITED CAPACITY 

Provide support for 

bringing food options 

to underserved 

communities 

A barrier to attracting healthy food 

retailers to underserved communities 

may include perceptions that 

businesses may suffer financially 

due to poor customer base, theft, 

or safety issues. Additionally, small 

stores may lack space, equipment, or 

staff expertise to carry fresh produce 

or to handle perishable foods. 

• Find mechanisms to support healthy food retailers 

who locate in underserved communities (e.g., 

simplify applications and permit procedures, 

bundle land to encourage supermarkets to locate 

in both affluent and low-income areas). 

• Provide support to help stores sell healthier 

options (e.g., staff training in handling perishable 

items, free local advertising). 

cdc.gov/healthequityguide 53
 

 

 

 

 

 

 

 

 

KEY FACTORS BARRIERS OR UNINTENDED OPPORTUNITIES TO MAXIMIZE IMPACT 

CONSEQUENCES 

ECONOMIC 

DEVELOPMENT 

Support local 

economic 

development 

through healthy 

food retail 

Retailers in underserved 

communities may not understand 

how they can support and enhance 

local economic development. 

• Connect local agriculture and food production 

directly to local markets to help keep food dollars 

in the community. 

• Establish workforce development programs to 

train local residents for high-quality jobs in a 

variety of food retail settings.114,115

• When making decisions about food retail, 

consider developing criteria to support 

businesses that contribute to local economic 

development (e.g., commitment to hire 

local residents). 

TRANSPORTATION 

NEEDS 

Address 

transportation 

challenges to 

increase access to 

healthy food retail 

Individuals who live in 

communities with poor access 

to healthy food retail and 

depend on public transit may 

have more difficulty transporting 

groceries—especially perishables 

and bulk packages. Even if 

affordable healthy food outlets 

are nearby, lack of transportation 

may prevent residents from 

accessing them. 

• Increase connectivity between transit and 

healthy food retail by assessing and improving 

existing routes. 

• Develop safe pedestrian connectors that provide a 

direct link between food outlets and nearby transit. 

• In rural areas, and for populations with limited 

mobility (e.g., the elderly, people with disabilities), 

consider offering vanpools or shuttles to healthy 

food options. 

• Provide online ordering and home delivery 

of healthy options for customers with 

transportation limitations. 

SAFETY & 

• Consider violence prevention strategies to create CONCERNS OF Community violence, real or safe routes and/or reduce concerns of safety on VIOLENCE perceived, may be a barrier to the way to healthy food destinations. 

shopping at healthy food retail Address concerns of in low-income communities. • See Preventing Violence Strategy in Active Living violence which may Section of this guide. serve as a barrier to 

healthy retail use 

cdc.gov/healthequityguide 54
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Build the Team: Partnership for Success 

Successful efforts to implement community food retail strategies depend on bringing a diverse set of 

partners to the table early, consistently, and authentically. These partners may include the following: 

• Area Agencies on Aging 

• Community development, revitalization, and 

redevelopment agencies and organizations 

• Community members (of diverse abilities, ages, 

cultures, gender, income levels, race/ethnicity, 

and sexual orientation) 

• Developers 

• Food banks 

• Health care systems, hospitals, community 

clinics, and health care providers 

• Housing agencies 

• Industry leaders 

• Leaders and community champions from 

multiple sectors 

• Local farmers and regional food distributors 

• Organizations serving populations experiencing 

health inequities 

• Public health agencies 

• Public Works Department 

• Retailers and vendors 

• Social service agencies 

• Zoning and Planning organizations 

cdc.gov/healthequityguide 55
 

HEALTH EQUITY IN ACTION 

Corner Store Initiative Supports Community Health and Local Store Owners 

Philadelphia, PA 

The driving force for a citywide healthy corner store 

effort came about when school leadership expressed 

concerns that healthy food policies in schools might 

drive students to purchase less healthy snacks at 

nearby corner stores. What started out as a smallscale initiative by The Food Trust to increase the 

availability of healthy foods, has grown from 10 

corner stores near schools to over 600 corner stores 

in low-income neighborhoods. Results from the 

Healthy Corner Store Initiative have brought health 

benefits not only to students, but also community 

residents who depend primarily on corner stores 

for food. These efforts have been supported by 

CDC’s Communities Putting Prevention to Work and 

Community Transformation Grant programs, as well as 

other non-federal funding. 

Health equity is a central tenet of the corner store 

efforts. Using existing relationships with local grocers 

associations (including mom-and-pop store owners), 

community groups, and school advocates, The Food 

Trust succeeded in establishing credibility with local 

corner store owners, making it easier to cultivate new 

relationships and get buy-in and support. By having 

a constant presence in the community and working 

closely with store owners to figure out good solutions, 

The Food Trust staff created a program that was viable 

and profitable for the owners. For example, the menu 

approach taken includes whole foods (e.g., whole-grain 

tortillas, beans, tofu) and low-fat dairy products, in 

addition to fresh produce. This allows store owners to 

select options that fit the store’s capacity, while being 

culturally appropriate for customers. Additionally, 

the program gave more stores a modest incentive 

to participate and allowed them to see the potential 

for increasing their profits. The process helped store 

owners see themselves as part of the community. 

The Food Trust is also focused on identifying 

sustainable solutions and offering additional 

supports for the most dedicated stores, such as 

cost-free training and technical assistance and larger 

infrastructure renovations (e.g., shelving, refrigeration) 

to accommodate more healthy food options. 

Through this initiative, The Food Trust was able 

to build a meaningful program that continues to 

benefit store owners and increases availability of 

healthy food for many low-income neighborhoods 

throughout Philadelphia. 

cdc.gov/healthequityguide 56
HEALTH EQUITY IN ACTION 

Improving Food Access and the Local Economy through Farmers’ Markets
�

Southwest Georgia 

The residents of Baker County in 

southwest Georgia (80% of whom 

are African American) live in a rural 

food desert. Over time, grocery 

store retailers abandoned the area, making it 

difficult for low-income residents with limited 

transportation to access healthy foods. The lack 

of grocery stores also impacted economic vitality 

in the community, leaving local farmers struggling 

to maintain their livelihood. To simultaneously 

address the resulting food access and economic 

issues, the East Baker Historic Society (EBHS) 

and the Southwest Georgia Project for 

Community Education began partnering with the 

Georgia StrikeForce Initiative and The Federation 

of Southern Cooperatives—organizations that 

assist African American and disadvantaged 

rural farmers—to repurpose unused public land 

for farmers’ markets in all 22 counties of the 

southwest region in Georgia. These efforts were 

supported by the United States Department 

of Agriculture and CDC’s Communities Putting 

Prevention to Work: State and Territorial Initiative. 

The farmers’ market development process began 

with identifying potential land. Next, community 

members, community-based organizations, 

local business owners, and government officials 

including commissioners and community 

development councils, participated in several 

strategic planning meetings, lending their 

input and getting approval to use public land. 

Disadvantaged farmers were identified and their 

needs were determined and addressed with 

training. When the market was ready to open, 

community activities, such as local high school 

band performances, were held to attract patrons. 

Residents with limited transportation now had 

access to nearby healthy food retail, African 

American and disadvantaged rural farmers gained 

customers to purchase their products, and town 

centers were revitalized with additional foot 

traffic from farmers’ market customers. 

By May 2012, four markets had opened. 

Southwest Georgia’s food desert is being revived 

with fresh foods—one farmers’ market at a time. 

cdc.gov/healthequityguide 57
 

 

 

 

 

HEALTHY RESTAURANTS AND CATERING TRUCKS 

HEALTHIER RESTAURANTS AND CATERING TRUCKS ARE EXAMPLES OF FOOD AWAY FROM HOME 

THAT MAY SERVE AS A MAJOR SOURCE OF FOOD IN SOME COMMUNITIES.116,117 STRATEGIES TO 

IMPROVE FOOD SELECTIONS IN THESE SETTINGS MAY INCLUDE PROMOTIONS AT THE POINT-OFPURCHASE, INCREASING THE RANGE OF HEALTHY FOOD OFFERINGS, AND PROMOTING THESE 

BUSINESSES THROUGH MEDIA AND EDUCATIONAL INITIATIVES. 

MAKE THE CASE: 

Why Is This A Health Equity Issue? 

The issues below highlight the need for healthy restaurant 

and catering truck strategies that advance health equity: 

• Higher Concentration of Full-Service and Fast Food 

Restaurants in Low- and Middle-Income Communities 

and Communities of Color: Low-income and middleincome communities and communities of color have 

been found to have more full-service and fast food or 

quick-service establishments compared to high-income 

communities.118-120 Eating away from home in food retail 

venues such as these has been linked to a variety of 

poor nutritional and health outcomes.121 

• Time and Economic Pressures May Contribute to 

Reliance on Prepared Food Sources: While time 

and economic pressures apply to most households, 

households with limited income may have a tighter 

budget for purchasing food. Members of these 

households may also have limited time because of 

working multiple jobs or having long commute times. 

Long distances to access resources may be even more 

common in rural areas.100,122 These time and economic 

pressures may contribute to individuals relying on 

quickly prepared food sources found at restaurants 

and catering trucks. 

• Targeted Marketing to Youth of Color Influences Food 

Choices: African American and Latino youth are often the 

target of ethnically-specific marketing initiatives by various 

food companies.123 Targeted marketing may increase the 

likelihood that youth will prefer and consume food options 

that may be calorie-dense and nutrient-poor, which may 

negatively affect their diet, weight, and health.123 

cdc.gov/healthequityguide 58
 

 

 

 

 

 

 

Design and Implement with Health Equity in Mind 

To maximize health impact and advance health equity, consider these factors and others when designing, 

implementing, and evaluating healthy restaurant and catering truck strategies: 

KEY FACTORS	� BARRIERS OR UNINTENDED OPPORTUNITIES TO MAXIMIZE IMPACT 

CONSEQUENCES 

TRUST & Retailers, particularly those in • Identify residents or partners with cultural and 

ENGAGEMENT underserved communities, may be community ties to engage and recruit retailers in 

overlooked for health-promoting health-related initiatives. 

Build relationships with initiatives due to cultural barriers retailers and overcome • Build trust by helping retailers with various aspects and misperceptions about their cultural barriers	� of their business (e.g., training staff, incorporating willingness to participate. healthy foods). 

COST Many smaller full-service and • Suggest changes to food preparation and Prioritize cost- quick-service restaurants and selection that are not only healthy, but also effective strategies catering trucks operate on thin cost-effective (e.g., offer whole beans in addition margins of profit and may be for food preparation to refried beans, switch from lard and margarine and food offerings reluctant to modify menus for fear to oils). of losing customers and revenue. 

PROMOTION 

• Encourage business owners to adopt healthy Provide cost-free Some small local businesses may practices by helping them with promotional 

promotion for not have marketing budgets to efforts (e.g., point-of-purchase signs) and restaurants with promote healthy food options. advertising (e.g., radio spots, newspaper ads). 

healthy items 

VARIABLE 

IMPLEMENTATION 

& ENFORCEMENT 

Ensure a 

comprehensive 

approach to nutrient 

labeling for nonchain, locally owned 

restaurants and 

catering trucks 

Nutrient labeling may be 

burdensome for non-chain 

restaurants and catering trucks. 

These establishments may lack 

standardized recipes and may 

not have the resources to 

conduct nutrient analyses.124 

Furthermore, some community 

members may not be responsive 

to nutrient labeling.125 

• Assess whether nutrient labeling is a viable 

strategy for your community. 

• Find partners to help save on the cost of 

nutrient analysis. 

• Build customers’ awareness and understanding of 

nutrient labeling and healthy food options (e.g., 

use symbols to simplify understanding of nutrient 

content, offer educational sessions). 

cdc.gov/healthequityguide 59
 

 

 

 

 

 

 

 

 

 

 

 

Build the Team: Partnership for Success 

Successful efforts to implement healthy restaurant and catering truck strategies depend on bringing a diverse 

set of partners to the table early, consistently, and authentically. These partners may include the following: 

• Community-based organizations working on • Local farmers and regional food distributors 

food systems, health, and/or agriculture 

• Public health agencies 

• Community development, revitalization, and 

• Public Works Department redevelopment agencies and organizations 

• Regional or local restaurant associations/ • Community members (of diverse abilities, ages, 

ethnic restaurants cultures, gender, income levels, race/ethnicity, 

and sexual orientation) • Restaurant and catering truck owners 

and managers • Faith-based organizations 

• Zoning and Planning organizations • Leaders and community champions from 

multiple sectors 

HEALTH EQUITY IN ACTION
�

Carryout Project Brings Healthful Foods to Low-Income Neighborhoods 

Baltimore, MD 

Low-income African Americans in Baltimore have 

been found to consume a significant portion of their 

calories from carryout facilities or restaurants.127 

These findings and others prompted Johns Hopkins 

researchers to create the Baltimore Healthy Carryout 

(BHC) project, with the goal of increasing healthy 

food options. The Baltimore Healthy Carryout 

intervention was funded by the Diabetes Research 

and Training Center, University of Maryland and Johns 

Hopkins University, as well as the Center for a Livable 

Future at Johns Hopkins University. 

Being sensitive to restaurant owners’ concerns that 

significant changes might drive away customers, 

BHC adopted a phased approach, implementing 

improvements over time. BHC staff maintained close 

contact with the owners, visiting each restaurant at 

least once a week. Through a series of discussions 

with community members, BHC staff members 

were able to gauge which healthy foods customers 

would want. These discussions guided the restaurant 

owners toward culturally and seasonally 

acceptable side options such as collard 

greens, watermelon, broth-based soup 

with vegetables, yogurt, and fruit cups. Carryout 

restaurants eventually began offering healthy combo 

meals (e.g., a healthy entrée with a healthy side 

instead of fries, bottled water in place of soda) that 

matched the price of original combo meals, making 

them accessible to price-sensitive groups. 

BHC also addressed concerns about potential profit 

loss by helping owners with promotion. Paper 

menus were replaced by more durable laminated 

signs. Literacy was considered during menu and 

poster creation, and images were used on the menus 

to help customers identify healthy choices. The 

modified menu boards and posters provided an 

aesthetic improvement, a co-benefit that business 

owners appreciated. BHC brought healthful foods to 

Baltimore residents in a way that supported existing 

local carryout businesses. 

cdc.gov/healthequityguide 60
HEALTH EQUITY IN ACTION 

Healthy Hometown Restaurant Initiative 

Louisville, KY 

Many people generally consume a large portion 

of their calories outside of the home in Louisville, 

KY.126 In an effort to promote healthy eating, 

Louisville Metro Public Health and Wellness 

(LMPHW), with support from CDC’s Communities 

Putting Prevention to Work program, 

implemented the Healthy Hometown Restaurant 

Initiative to encourage restaurants to provide 

healthier options for their patrons. A voluntary 

menu-labeling resolution was implemented that 

included a nutrition analysis of meals with printed 

calorie information and recommendations for 

healthier menu choices. 

LMPHW learned that the community’s strong 

social connectedness provided a benefit when 

trying to get buy-in from restaurant owners. 

Restaurateurs were most motivated to join if they 

were approached by individuals they trusted, 

and if those individuals thought their customers 

wanted the change. 

Initially, LMPHW conducted community 

surveys through the University of Louisville 

and local youth, hosted professional cooking 

demonstrations, and attended business 

association meetings. These activities helped 

spread the word about the restaurant initiative to 

residents and restaurant owners. However, only 

restaurants located in affluent neighborhoods 

were responding. To engage restaurant owners 

in Louisville’s low-income neighborhoods, 

outreach coordinators conducted in-person 

visits to restaurants. LMPHW overcame owner 

hesitation by engaging champions including 

a neighborhood association and the owner of 

a local restaurant who had previously signed 

on to the initiative. The champions spread the 

word about the Healthy Hometown Initiative and 

encouraged other restaurateurs to join. Their 

local outreach led five additional restaurants to 

join the initiative. 

cdc.gov/healthequityguide 61
 

 

 

HEALTHY FOOD IN SCHOOL, AFTERSCHOOL, AND 

EARLY CARE AND EDUCATION ENVIRONMENTS 

HEALTHY FOOD AND BEVERAGES STRATEGIES TO IMPROVE THE HEALTH OF CHILDREN MAY 

INCLUDE THE DEVELOPMENT AND IMPLEMENTATION OF POLICIES AND PRACTICES (E.G., 

WELLNESS POLICIES, NUTRITION STANDARDS FOR COMPETITIVE FOODS, WATER AVAILABILITY), 

IN SCHOOL, AFTERSCHOOL, AND EARLY CARE AND EDUCATION ENVIRONMENTS. 

MAKE THE CASE: 

Why Is This A Health Equity Issue? 

The issues below highlight the need for healthy food and 

beverage strategies that advance health equity: 

• Low-Income Children May Be More Dependent on 

Foods Provided in School, Afterschool, and Childcare 

Settings: Many children benefit from and rely on meals 

served in school, afterschool, and childcare settings for 

much of the food they consume per day.128-132 Specifically, 

many children from low-income households qualify for free 

or reduced-price meals and participate in food programs 

such as the National School Lunch Program, the School 

Breakfast Program, and the Child and Adult Care Food 

Program.132-135 However, some barriers may keep children 

who qualify for free and reduced-price meal programs 

from enrolling and benefiting from these services.136-138 For 

instance, lack of information about the application process, 

language and literacy challenges, lack of cultural sensitivity 

and appropriateness of the food served, and stigma 

associated with participating in these programs138,139 may 

serve as barriers to enrollment and participation. 

• Settings May Differ in Their Capacity to Provide 

Healthy Food Environments: The quality of food may 

vary substantially between and within different settings 

(e.g., school districts, public and private settings). Some 

settings may be more constrained by limited budgets, 

and others may have limited facilities in which to prepare 

and serve food. Additionally, some schools may rely on 

the revenues generated from competitive foods, including 

vending sales, to support various school functions and 

activities.140,141 These constraints may contribute to less 

healthy food environments for children in these settings. 

cdc.gov/healthequityguide 62
 

 

 

 

 

 

 

 

 

 

 

 

Design and Implement with Health Equity in Mind 

To maximize health impact and advance health equity, consider these factors and others when designing, 

implementing, and evaluating healthy food and beverage strategies: 

KEY FACTORS	� BARRIERS OR UNINTENDED OPPORTUNITIES TO MAXIMIZE IMPACT 

CONSEQUENCES 

VARIABILITY IN 

IMPLEMENTATION 

Provide additional 

supports to underresourced school, 

afterschool, and 

childcare settings 

The resources available to 

institutions may affect their ability 

to improve their food environment. 

• Provide additional staff training or technical 

assistance in settings with fewer resources. This 

assistance may help maximize enrollment in meal 

programs and preparation of healthy foods. 

• Explore alternatives for institutions with limited 

facilities for the preparation and storage of foods/ 

snacks (e.g., develop agreements with nearby 

institutions to use their facilities, use mobile 

vending carts). 

PARTICIPATION 

Reduce barriers 

to enrollment and 

increase overall 

participation in 

meal programs 

Barriers may keep many eligible 

children from benefiting from these 

programs.136,137 Additionally, time 

constraints and lack of sensitivity 

to cultural and religious food 

preferences may limit participation 

in meal programs. 

• Make it easier for parents to enroll children by 

making them aware of eligibility and providing 

assistance with paperwork in multiple languages. 

• Take advantage of automatic or school-wide 

enrollment options, especially in low-income settings. 

• Adjust the time and length of meals to ensure 

children have time to get and eat lunch. 

• Train staff to be aware of the cultural backgrounds 

of students in preparation of a culturally 

appropriate food menu. 

• Work with stakeholders to identify efforts to 

prevent obvious identification of eligible students. 

STIGMA • Consider avoiding separate lines for competitive 

Take steps to reduce Stigma may act as a barrier to foods and food programs. Provide the same food 

stigma associated participation in meal programs.138,139 options to all students. 

with meal programs • Explore a cashless point-of-sale system where all 

students have an account in a database. 

LACK OF 

Many children may have limited EXPOSURE access to and familiarity with 

Increase exposure healthy foods, particularly children 

to healthy foods from underserved communities. 

• Find opportunities to increase students’ exposure 

to healthy foods (e.g., farm-to-school partnerships, 

gardening programs). 

• Work with schools to serve as sites for farmers’ 

markets on the weekends or during child pick-up 

hours to increase healthy food access. 

• Consider strategies to make healthy options 

more commonplace (e.g., discourage use of less 

healthy food as a reward, encourage fundraising 

activities that include healthy options, offer healthy 

competitive foods and vending). 

cdc.gov/healthequityguide 63
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Build the Team: Partnership for Success 

Successful efforts to implement healthy food and beverages strategies in school, after-school, and childcare 

environments depend on bringing a diverse set of partners to the table early, consistently, and authentically. 

These partners may include the following: 

• Board of Education members 

• Childcare licensing agencies 

• Childcare staff 

• Community-based organizations such as YMCA, Boys and 

Girls Club, sports associations, Boy Scouts, Girl Scouts 

• Community members (of diverse abilities, 

ages, cultures, gender, income levels, race/ethnicity, 

and sexual orientation) 

• Food service managers and staff 

• Local chefs 

• Leaders and community champions from multiple sectors 

HEALTH EQUITY IN ACTION 

• Local food organizations 

• Parents and students 

• Parks and recreation agencies 

(for afterschool and summer programs) 

• Principals 

• Public health agencies 

• School district administrators 

• School Health Councils 

• Teachers 

• Vendors 

Tailored Institutional Practices to Increase Access to Healthy Foods in Childcare Centers
�

Southern Nevada 

Many Southern Nevada children lack access to 

healthful food and opportunities for physical activity.142 

This fact, as well as the childhood obesity rates,143 

prompted the Southern Nevada Health District 

(SNHD) to support childcare centers in implementing 

institutional health-promoting practices and policies. 

Budgetary constraints spurred the district to explore 

no- to low-cost sustainable solutions. 

With support from CDC’s Communities Putting 

Prevention to Work program, the SNHD Community 

Health Division worked with the district’s Division of 

Nursing to provide training to childcare center staff 

and one-on-one guidance in developing healthy 

food and physical activity practices and institutional 

policies. To ensure these efforts reached the children 

most in need, the district targeted high-need childcare 

centers, including casinos and other places with high 

rates of unemployment and participation in needbased programs. 

By March 2012, more than 65 centers had implemented 

institutional nutrition and physical activity policies 

informed by a best practice policy drafted by the Health 

District. Each center was able to craft an institutional 

policy that was most appropriate for it and most feasible 

for implementation. This flexibility gave each center 

ownership over its institutional practices instead of 

requiring a standardized approach that might not have 

accounted for each center’s unique level of resources 

and needs. 

Each participating center received a curriculum designed 

specifically for childcare centers and used it to help 

establish staff development opportunities. Worth at least 

four continuing education units (CEUs), the curriculum 

and related training provided an incentive to each 

center’s support staff to learn how to promote healthy 

behaviors. Staff can work toward fulfilling a state law 

that requires licensed childcare professionals to attain 

15 CEUs per year, with at least two of those hours in the 

areas of childhood obesity, physical activity, nutrition, or 

wellness. Childcare center staff now have the training, 

resources, and the incentive to have an impact on 

childhood obesity in Southern Nevada. 

cdc.gov/healthequityguide 64
HEALTH EQUITY IN ACTION
�

Centralized Kitchen Facilitates Healthy Meals for All Schools
�

Bibb County, GA 

Helping students learn is part of the mission of 

the Bibb County School Nutrition program.144 

The program helps keep students focused and 

alert by ensuring every student has access to 

nutritious food. Through collaborative efforts 

with school nutrition, school administrators, and 

Title I Home-School Facilitators providing in-kind 

and other support, Bibb County, GA wanted to 

remove barriers to healthy food access in schools 

by encouraging all families to apply for free and 

reduced-price meals. They also implemented 

a meal accounting system for all students. The 

system is intended to reduce stigma and prevent 

obvious identification of students enrolled in the 

meal program. 

Bibb County also built a centralized kitchen for 

basic prep work and cooking to ensure that each 

of the county’s 41 schools could serve healthy 

meals. The kitchen provides meals made from 

basic healthy ingredients, using little sugar, salt, 

and fat and no preservatives. The centralized 

kitchen has allowed each school to implement 

healthier food options without investing in 

significant kitchen equipment or staffing changes. 

For example, schools can phase out fryers 

without purchasing new equipment. 

Bibb County already had finishing 

kitchens in each school, and efforts 

focused on ensuring that equipment to 

prepare healthy meals was equitably 

available across the district. The district 

intentionally created a standardized menu to 

ensure that all schools serve healthy options 

without sacrificing taste, diversity, or appeal. 

Menu options have included “harvest of the 

month” items such as fresh beets, sweet potatoes, 

brussels sprouts, and locally grown strawberries. 

Daily vegetarian options feature choices such as 

black bean empanadas or veggie burgers. For 

districts that cannot afford a centralized kitchen, 

Dr. Cleta Long, Director of the Bibb County 

School Nutrition Program, suggests: “Centralize 

specific preparation within different schools... 

one school handles entrees, one school is a 

bakery, one makes sauce.” By creating a parallel 

distribution system, districts can still serve fresh, 

healthy food in every school even when kitchen 

equipment and staff are limited. 

cdc.gov/healthequityguide 65
 

 

FOOD ACCESS THROUGH LAND USE PLANNING AND 

POLICIES 

LAND USE PLANNING AND POLICIES TO IMPROVE FOOD ACCESS MAY INCLUDE 

ATTRACTING HEALTHY FOOD RETAIL (E.G., SMALL BUSINESSES, MOBILE VENDING), 

LIMITING THE DENSITY OF LESS HEALTHY FOOD RETAIL, AND PERMITTING URBAN 

AGRICULTURE AND COMMUNITY GARDENS. 

MAKE THE CASE: 

Why Is This A Health Equity Issue? 

The issues below highlight the need for land use planning 

strategies that advance health equity: 

• Historical Land Use Policies and Practices Have Shaped 

Community Resources: Historically, land use strategies, 

such as zoning regulations, were used to separate 

residential areas from industrial areas. However, some 

of these strategies were used to segregate groups of 

people based on race, ethnicity, or income status.145-147 

Such land use decisions and other issues have left many 

low-income and communities of color with limited access 

to essential services, facilities, and infrastructure,145,148-151 

including food resources. 

• Barriers to Healthy Food Options May Exist in 

Underserved Communities: The density of fast food 

outlets has been found to be higher, and the availability 

of supermarkets is lower, in low-income communities and 

communities of color.108,110,120 Additionally, low-income 

communities and communities of color may have higher 

food prices for healthy food than high-income and white 

communities.105,108,110,111 The quality of healthy food may also 

be lower in these underserved communities.108,110,111 Land 

use planning and policies can be used to improve the food 

options in a community. 

Note: As many land use and zoning strategies fall in the purview of other 

sectors, public health agencies should work with appropriate partners when 

considering such strategies. 

cdc.gov/healthequityguide 66
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Design and Implement with Health Equity in Mind 

To maximize health impact and advance health equity, consider these factors and others when designing, 

implementing, and evaluating land use planning strategies to improve access to healthy food: 

KEY FACTORS	� BARRIERS OR UNINTENDED OPPORTUNITIES TO MAXIMIZE IMPACT 

CONSEQUENCES 

COMMUNITY 

AWARENESS & 

INVOLVEMENT 

Engage residents 

who lack access 

to healthy food in 

planning and 

policy development 

Historically, low-income populations 

and communities of color have 

been excluded from, or not actively 

recruited into, land use planning and 

policy development.145 

• Partner with organizations that have credibility and 

ties to residents to foster meaningful engagement. 

• Provide training to build residents’ leadership 

skills and increase their understanding of the 

planning process. 

• Establish systematic processes to ensure that 

resident concerns are gathered and reflected in 

land use plans when they are updated. 

DISPLACEMENT 

Make improvements 

to food retail 

in underserved 

communities with 

current residents 

in mind 

Economic development including 

new food retail may result in 

increases in property values and 

rent. If such changes occur, existing 

residents may be displaced if they 

are unable to afford living there. 

• Ensure comprehensive plans outline how 

improvements in food access will affect other 

priorities such as housing and jobs (e.g., incentivize 

local hiring for new food retailers). 

• Align transportation decisions (e.g., transit hub 

locations, bus routes), with food access needs, 

particularly for those who may depend on transit 

(e.g., people with disabilities, the elderly). 

DISPROPORTIONATE 

NEGATIVE EFFECTS 

Be aware that the 

same methods used 

to attract healthy 

options may also be 

used to bring in less 

healthy options 

Efforts to attract healthy food 

retail may inadvertently allow or 

incentivize less healthy options. For 

example, retailers in underserved 

communities may be accustomed 

to selling low-cost and less healthy 

food options, and may use any 

incentives to continue selling these 

items, instead of healthier options. 

• Consider linking specific requirements for healthy 

food to any incentives to attract or enhance food 

retail, particularly in underserved communities. 

• Provide support to food retail outlets operating 

in food deserts that meet some established 

healthy food requirements (e.g., additional 

vending permits, training, Electronic Benefit 

Transfer (EBT) equipment). 

Build the Team: Partnership for Success
�

Successful efforts to implement land use planning strategies to increase access to healthy food depend 

on bringing a diverse set of partners to the table early, consistently, and authentically. These partners may 

include the following: 

• Community development, revitalization, and 

redevelopment agencies and organizations 

• Community members (of diverse abilities, ages, 

cultures, gender, income levels, race/ethnicity, 

and sexual orientation) 

• Developers 

• Food system coalitions and organizations 

• Leaders and community champions from 

multiple sectors 

• Local economic development agency 

• Local farmers and regional food distributors 

• Public health agencies 

• Organizations serving populations experiencing 

health inequities 

• Public Works Department 

• Retailers and vendors 

• Social service agencies 

• Zoning and Planning organizations 

cdc.gov/healthequityguide 67
 

 

HEALTH EQUITY IN ACTION
�

Massachusetts Ave Project (MAP) Growing Green Youth listen as city officials introduce Buffalo's Green Code (form-based rezoning effort) during 

participation in a public meeting in Buffalo,NY. (2011). Photo courtesy of MAP. 

Using Planning and Zoning to Create Access to Healthy and Affordable Foods 

Buffalo, NY 

An unstable economy has left the once-thriving 

city of Buffalo with a declining population, 

unemployment,152 high rates of poverty, and 

chronic disease.153 It has also left a large number of 

vacant lots. While some may view vacant lots as 

blight, residents saw an opportunity to turn them 

into community gardens. However, the current 

comprehensive plan and zoning code was difficult 

for residents to navigate. 

A team led by Dr. Samina Raja, Associate Professor 

at the University of Buffalo, works with the 

Massachusetts Avenue Project (MAP), a communitybased organization, to tackle one of Buffalo’s 

biggest challenges - food insecurity. In 2008, the 

University team mapped grocery stores and found 

there were fewer grocery stores in communities 

of color than predominately white communities. 

MAP took on this challenge by bringing a mobile 

market to neighborhoods without a grocery store to 

increase residents’ access to healthy and affordable 

foods; but an existing zoning ordinance restricted 

where the vehicle could park. 

Through a partnership with the Buffalo Niagara 

Medical Campus, several organizations including 

the University of Buffalo, MAP, and others formed 

Healthy Kids, Healthy Communities (with support 

from the Robert Wood Johnson Foundation)—at a 

time when Buffalo was focusing its efforts on policy 

improvement strategies. Buffalo was undergoing 

an update of its land use plan and zoning code, and 

the partnership saw an opportunity to highlight the 

links between zoning and food access. Youth from 

MAP’s programs and other groups in Buffalo were 

invited to help educate community stakeholders on 

the benefits of improving access to healthy food 

sources. They also discussed the impact of zoning 

codes on growing healthy and culturally appropriate 

food in the community. 

As a result of these educational efforts, the mayor 

announced his support of strategies that promote 

access to healthy foods at the first Buffalo Food 

Policy Summit. The city of Buffalo will likely 

implement a zoning code that supports an equitable 

food environment by including strategies such as 

making market gardens a permissible land use. In 

addition, the Food Policy Council of Buffalo and 

Erie County was created by the Erie County Board 

of Health, and will provide support and act as a 

resource on food systems and its impact on the 

health of the community. 

cdc.gov/healthequityguide 68
HEALTH EQUITY IN ACTION
�

How a Model for Social Change Led to 

Grocery Stores and a Fast Food Moratorium 

Los Angeles, CA 

South Los Angeles residents suffer from disproportionate 

rates of chronic disease154 and low life expectancy.155 

In 1992, the nonprofit organization Community Health 

Councils (CHC) formed to address the health care 

safety net crisis in Los Angeles. Seven years later, health 

disparities loomed large in South LA, and CHC explored 

the root causes of these inequities. Using a model for 

social change grounded in community engagement and 

coalition building, CHC focused on inequities surrounding 

food and the built environment. The group took the 

time to build key relationships, an important step for 

addressing unintended consequences as they arose. 

Community members, churches, and community-based 

organizations, in collaboration with CHC, led an intensive 

assessment that documented disparities in food access 

with support from CDC’s Racial and Ethnic Approaches 

to Community Health program. Over 100 residents 

participated, many traveling to West LA (an area with 

some of the best health outcomes in the county) to note 

differences in the types of food available. Compared with 

West LA, South LA lacked sufficient grocery stores that 

carried healthful foods and faced an overabundance of 

fast food restaurants. The inequity in access to healthy 

foods became apparent, and community forums spurred 

dialogue about environmental impacts on health. 

Residents envisioned what a healthy South LA would 

look like and determined that healthy food options 

were critical. With this groundwork and support from 

the community, CHC explored strategies to address 

the density of fast food restaurants and attract grocery 

stores. The City Council approved a Grocery Store and 

Sit-Down Restaurant Incentive package that created 

economic incentives for attracting healthy food retailers 

to South LA. Building upon relationships with the local 

planning department, CHC also worked to support the 

implementation of other strategies to create a healthier 

food environment. In 2008, the Los Angeles City Council 

established an interim control policy that placed a 

moratorium on permits for new stand-alone fast food 

restaurants in the targeted neighborhoods for a maximum 

Examples of food options predominant in South Los Angeles,CA. 

Photo courtesy of Community Health Councils. 

two-year period. The moratorium later became 

a permanent policy in the form of a general plan 

amendment preventing the development of new 

stand-alone fast food restaurants within a halfmile of an existing establishment. 

By focusing on the needs identified by community 

members, CHC made meaningful strides toward 

improving the food environment. Community 

members were involved in every step of the 

process. Lark Galloway Gilliam, Executive Director 

of CHC stated the key to a successful initiative: 

“Don’t leave the community behind. Let the 

community lead.” 

cdc.gov/healthequityguide 69
 

 

 

BREASTFEEDING PRACTICES AND POLICIES
�

SUPPORTIVE BREASTFEEDING STRATEGIES TO IMPROVE THE INITIATION, EXCLUSIVITY, AND 

DURATION OF BREASTFEEDING MAY INCLUDE ADDRESSING HOSPITAL PRACTICES (E.G., 

BABY-FRIENDLY HOSPITAL INITIATIVE156), SUPPORTING WORKPLACE ACCOMMODATIONS, 

AND BUILDING SUPPORTIVE COMMUNITY ENVIRONMENTS. 

MAKE THE CASE: 

Why Is This A Health Equity Issue? 

The issues below highlight the need for breastfeeding 

strategies that advance health equity: 

• Inadequate Access to Services and Support for Some 

Populations Experiencing Inequities: Breastfeeding 

rates are lowest among African American mothers157,158 and 

mothers living in rural areas.157,159,160 Several factors may 

account for lower rates of breastfeeding among African 

American mothers, including how they are treated by health 

care providers with respect to breastfeeding encouragement 

and information.161 For mothers in rural areas, factors such 

as poverty and inadequate access to needed maternity and 

health services may serve as barriers to breastfeeding.159,162

• Limited Access to Breastfeeding Support in the 

Workplace: Mothers returning to the workplace may face 

several barriers to breastfeeding due to workplace conditions 

(e.g., break time for pumping, onsite storage) and the level 

of benefits provided (e.g., maternity leave).157 For instance, 

many mothers do not have paid maternity leave. Additionally, 

those with lower incomes and those in the service and 

manufacturing fields have been found to have even lower rates 

of paid maternity/family leave.157 Breastfeeding may also be 

particularly challenging for hourly, low-wage mothers as they 

may have less flexibility and break options.157,163

• Social Norms May Serve as a Barrier for Underserved 

Communities: Social norms such as lack of support 

from family and friends161 and not having examples of 

breastfeeding157,164 may be barriers for some population 

groups. Additional barriers may include norms around the 

sexual role of breasts as opposed to their nurturing function of 

breastfeeding, and perceptions of breastfeeding as an unusual 

feeding option.157,164

cdc.gov/healthequityguide 70
 

 

 

 

 

 

 

 

 

Design and Implement with Health Equity in Mind 

To maximize health impact and advance health equity, consider these factors and others when designing, 

implementing, and evaluating breastfeeding strategies: 

KEY FACTORS	� BARRIERS OR UNINTENDED OPPORTUNITIES TO MAXIMIZE IMPACT 

CONSEQUENCES 

LIMITED 

RESOURCES & 

CAPACITY 

Address challenges 

to implementing 

hospital practices that 

increase breastfeeding 

initiation 

The process required for 

achieving official Baby-Friendly 

Hospital designation may seem 

too rigorous for some facilities 

or present barriers within 

overburdened hospitals. 

• Provide additional support to hospitals serving 

populations with disparities in breastfeeding 

to help them work toward Baby-Friendly 

Hospital designation. 

• Understand challenges to implementing 

Baby-friendly Hospitals and work with hospitals 

to identify and implement incremental steps 

toward encouraging breastfeeding. 

VARIABILITY IN 

CARE PROVIDED 

Ensure sufficient 

breastfeeding support 

from health care 

providers and staff 

Varying cultural and 

socioeconomic factors, as well 

as a lack of information on 

breastfeeding, may result in 

some women not receiving the 

support they need to initiate and 

continue breastfeeding.165 

• Train providers on breastfeeding disparities and 

approaches to address cultural and economic 

barriers to ensure they provide appropriate 

breastfeeding education to all. 

• Encourage hospitals to partner with the 

Women, Infants, and Children Program (WIC)166 

to ensure continuity of breastfeeding support for 

low-income mothers following discharge. 

TRAINING 

NEEDS 

Provide adequate 

and culturally 

competent training 

for peer counselors 

who provide 

breastfeeding advice 

• Encourage use of properly trained peer counselors, 

along with professional support, to provide 

Mothers may get discouraged culturally tailored support for breastfeeding.157,167

from breastfeeding when they face • Partner with WIC and other organizations to challenges and do not have support identify residents who reflect the cultural values from properly trained individuals. of breastfeeding mothers and can be trained as 

peer counselors. 

VARIABILITY IN 

ADOPTION & 

IMPLEMENTATION 

OF BREASTFEEDING 

STRATEGIES 

Collaborate with 

community resources 

to enhance worksite 

breastfeeding support 

Some employers, including those 

that employ low-wage staff, may 

not understand how to properly 

accommodate breastfeeding 

workers. They may also lack the 

resources and infrastructure (e.g., 

space, refrigeration) to comply with 

breastfeeding regulations. 

• Reach out to employers, including those 

that employ low-wage staff, to address 

workplace barriers and provide support for 

breastfeeding accommodation. 

• For smaller businesses, consider addressing 

barriers by building partnerships among 

employers located close to one another to 

combine resources (e.g., establish one common 

space that can be used by all their employees). 

• Find creative solutions to provide information 

and accessible spaces for breastfeeding mothers 

(e.g., leverage existing community infrastructure 

such as faith-based institutions, libraries, 

childcare centers). 

cdc.gov/healthequityguide 71
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Build the Team: Partnership for Success 

Successful efforts to implement supportive breastfeeding strategies depend on bringing a diverse set of 

partners to the table early, consistently, and authentically. These partners may include the following: 

• Chambers of commerce • Health care systems, hospitals, community 

• Childcare centers and provider organizations clinics, and health care providers 

(e.g., Head Start) • Local businesses 

• Community-based organizations • Local/regional employers (particularly 

• Community members (of diverse abilities, ages, employers of low-income, hourly workers) 

cultures, gender, income levels, race/ethnicity, • Public health agencies 

and sexual orientation) • Regional and local breastfeeding coalitions 

• Cultural institutions and networks (e.g. La Leche League, lactation consultants) 

• Faith-based organizations • Social service agencies 

• Family members • State and local WIC programs 

HEALTH EQUITY IN ACTION 

Promoting Baby-Friendly Hospitals to Increase Equity
�

Los Angeles, CA 

Of the 50 California counties where births occur, Los 

Angeles County ranked 43rd out of 50 for exclusive 

breastfeeding rates. Furthermore, Los Angeles 

County housed 9 of the 15 lowest scoring hospitals in 

the state.168 In response, Breastfeed LA: Breastfeeding 

Task Force of Greater Los Angeles collaborated with 

the Regional Perinatal Programs of California to 

provide training and technical assistance to improve 

the quality of maternal care and guide hospitals 

toward the Baby-Friendly Hospital designation. 

In 2008 and 2009, Breastfeed LA reached out to 

hospital decision makers, emphasizing breastfeeding 

as a quality improvement indicator and promoting 

baby-friendly practices. Focusing on three counties 

with the lowest rates of exclusive breastfeeding, the 

group provided bedside nurse and train-the-trainer 

workshops using the Birth and Beyond California169 

curriculum. Priority was given to hospitals with high 

birth rates, high rates of Medi-Cal (state Medicaid) 

use, and low breastfeeding rates. The funding for this 

project was from the California 

Department of Public Health Federal Title 

V Maternal and Child Health Block Grant. 

Hospital participation in some areas was 

sluggish at first. To overcome lack of 

1%

milk

interest, Breastfeed LA, with funding from 

First 5 LA, encouraged local public health officials to 

become champions by making the case to hospitals 

that breastfeeding is a public health issue. Grants 

were given to targeted hospitals from the First 5 LA 

Baby-Friendly Hospital Project, which helped these 

hospitals overcome the cost barrier for staff training 

and systems improvements. These hospitals primarily 

serve women of color and low-income women. 

Collaborative learning has been a key strategy. 

Breastfeed LA and the Los Angeles County 

Department of Public Health are convening three 

Regional Hospital Breastfeeding Consortia where 

lower performing hospitals can learn from higher 

performing ones. Since the Consortia kickoff in April 

2010, 11 LA hospitals have achieved Baby-Friendly 

Hospital designation. Many more are in the process. 

Note: Breastfeed LA is a partner with the County of Los Angeles, Department of Public Health to continue the vital work of encouraging and guiding 

hospitals to improve maternity care practices and ultimately achieve Baby-Friendly designation. With support from CDC’s Communities Putting 

Prevention to Work program, the three County Hospitals achieved the Baby-Friendly Designation, and technical assistance is being provided to 16 

additional hospitals with support from CDC’s Community Transformation Grants program. 

cdc.gov/healthequityguide 72
HEALTH EQUITY IN ACTION 

Family participating in the Healthy Start Brooklyn program. Photo Courtesy of Healthy Start Brooklyn. 

Building Community Capacity to Support Breastfeeding 

New York, NY 

Breastfeeding initiation rates in central Brooklyn 

hospitals were high,170 but women may have 

found breastfeeding challenging to maintain 

and integrate into their daily routines.171 With 

funding from the Health Resources and Services 

Administration, Healthy Start Brooklyn (HSB) 

found innovative ways to support these women. 

Coordinated efforts that focused on five lowincome, predominantly African American and 

Latino neighborhoods created empowerment 

zones to shift breastfeeding practices and norms. 

The By My Side program was developed to deliver 

low-cost services to low-income and immigrant 

women. It also opened up job opportunities for 

women living in the targeted neighborhoods. 

Women were trained as doulas, providing 

emotional, physical, and informational support to 

mothers during delivery and conducting home 

visits before and after birth. Doula services 

that are typically available to higher-wealth 

communities are now accessible by low-income 

families through By My Side. The doulas also 

serve as lactation consultants, offering guidance 

on how to breastfeed and linking mothers to 

resources such as HSB’s Breastfeeding 911! Hotline. 

Program results show that mothers who have 

used a doula have higher rates of exclusive 

breastfeeding. In addition to integrating doula 

services into hospital practices, HSB has reached 

out to organizations with strong community ties 

to initiate culturally appropriate breastfeeding 

support, expanding the training program so 

organizations can offer their own doula services. 

By March 2012, the program had successfully 

trained more than 30 women in the community. 

These doulas, along with those already working 

for By My Side, have participated in more than 

100 births. 

HSB supports the continuation of breastfeeding 

behaviors beyond hospital doors by shifting 

community norms, creating new long-term 

economic opportunities, and improving the lives 

of women and their families overall. Some 125 

faith-based institutions now have breastfeeding 

spaces and signs on their premises. Working with 

pharmacies to provide a space for breastfeeding 

in their stores is a next step. 

cdc.gov/healthequityguide 73
-

 

 

 

 

 

 

 

-

 

 

 

SECTION 4 Maximizing Active Living Strategies 

to Advance Health Equity

USE THE CONTENT TO: 

• FOSTER DIALOGUE 

ON HEALTH EQUITY 

CONCERNS WITHIN 

A COMMUNITY. 

• TRAIN STAFF AND 

PARTNERS ON 

EQUITY ISSUES 

REGARDING ACTIVE 

LIVING STRATEGIES. 

• IDENTIFY WAYS TO 

ADDRESS HEALTH 

EQUITY IN THE 

DESIGN AND 

IMPLEMENTATION 

OF STRATEGIES. 

• DEVELOP YOUR OWN 

APPROACH FOR 

ENSURING EFFORTS 

ARE ADDRESSING 

HEALTH INEQUITIES. 

Not all communities have equal access to physical activity resources or 

environments that support an active lifestyle. Low-income communities and 

communities of color have been found to have limited facilities and spaces for 

physical activity, poor sidewalk and street infrastructure, and disproportionate 

exposure to violence.172-176 These hindrances may deter or limit opportunities 

for those populations to engage in physical activity. Additionally, the physical 

activity infrastructure that does exist in many communities, low-income 

or not, may not be developed with all potential users in mind. As a result, 

populations with special needs such as the elderly and people with disabilities 

may not be properly accommodated.177 180

The Active Living section of A Practitioner’s Guide for Advancing Health 

Equity provides equity-oriented considerations, key partners, and community 

examples related to the design and implementation of the following strategies: 

• Joint Use Agreements 

• Safe and Accessible Streets for All Users 

• Trails and Pathways to Enhance Recreation and Active Transportation 

• Physical Activity in School, Afterschool, and Early Care and Education Settings 

• Neighborhood Development that Connects Community Resources to Transit 

• Preventing Violence 

The content presented is not exhaustive and is not intended to act as a “how 

to” guide. Rather, this section aims to stimulate ideas for ensuring active living 

strategies are designed to address the needs of populations experiencing 

health inequities. Refer to disclaimer on page iii when using this Section. 

cdc.gov/healthequityguide 74
 

 

 

JOINT USE AGREEMENTS 

JOINT USE (OR SHARED USE) AGREEMENTS CAN INCREASE RESIDENTS’ ACCESS TO SAFE 

PHYSICAL ACTIVITY RESOURCES BY ALLOWING RESIDENTS TO USE EXISTING COMMUNITY 

FACILITIES (E.G., PLAYGROUNDS, GYMS, POOLS). 

MAKE THE CASE: 

Why Is This A Health Equity Issue? 

The issues below highlight the need for joint use 

agreements that advance health equity: 

• Differential Access to Physical Activity 

Resources: Access to physical activity 

resources (e.g., parks, bike paths, 

playgrounds) may differ by community, 

socioeconomic status, and race.176,181,182 For example, 

lower-income neighborhoods and communities of 

color generally have fewer such facilities.176 

• Additional Challenges to Using Physical Activity 

Resources: Even when physical activity resources 

are geographically close and appear accessible, some 

residents may encounter barriers which may limit 

the use of these resources. Barriers may include 

neighborhood safety concerns, lack of transportation, 

lack of time, or expenses related to the facility.183 

Additionally, existing social and community norms or a 

lack of universally accessible facilities for older adults 

and those with mobility issues can be barriers. 

• Fewer Joint Use Agreements in Underserved 

Communities: After-hours access to facilities such 

as schools may differ depending on communities’ 

socioeconomic and racial/ethnic composition. For 

example, certain communities may experience or 

perceive more barriers to implementation of joint use 

agreements. These barriers may include concerns 

about crime and vandalism, as well as costs related to 

liability, maintenance, or operations.181,184-186

cdc.gov/healthequityguide 75
 

 

 

 

 

 

 

 

 

 

 

 

 

 

Design and Implement with Health Equity in Mind 

To maximize health impact and advance health equity, consider these factors and others when designing, 

implementing, and evaluating joint use agreements: 

KEY FACTORS	� BARRIERS OR UNINTENDED OPPORTUNITIES TO MAXIMIZE IMPACT 

CONSEQUENCES 

• Engage violence prevention partners during 

SAFETY Concerns about neighborhood planning to address safety concerns. safety and vandalism can keep Promote safety to physical activity resources locked • If possible, implement joint use agreements near 

ensure implementation or underutilized after-hours, or in facilities where residents already feel safe. 

and use of joint use particularly in areas where physical • Use environmental design strategies (e.g., improving agreements activity resources are needed most. lighting, limiting or maintaining shrubbery) to 

enhance safety. 

LIABILITY 

CONCERNS 

Address liability concerns 

related to joint-use 

agreements, particularly 

in high-crime areas 

Under-resourced communities may 

have heightened liability concerns 

due to factors such as older facilities 

and higher crime rates. Such 

concerns may hinder facilities from 

implementing joint use agreements. 

• Identify and address barriers and concerns of 

community partners who may be resistant to 

joint use agreements. 

• Assess existing coverage status of joint use 

partners, as many schools and recreation partners 

may already be sufficiently covered. 

FUNDING 

LIMITATIONS 

Establish partnerships 

to secure funding 

and sustain joint use 

agreements 

Under-resourced communities may 

have concerns regarding funding, 

personnel, and maintenance to keep 

facilities open outside of normal 

business hours. 

• Combine resources from multiple partners to 

create stable funding for initial implementation, 

as well as ongoing operations, maintenance, 

and programming. 

• Consider multiple funding sources to support joint 

use agreements (e.g., grants, state/local bonds, 

developer fees, tax increment financing). 

• When funds become available, direct funds to 

low-resource communities where physical activity 

opportunities are needed most. 

COMMUNITY 

AWARENESS & 

INVOLVEMENT 

Engage residents 

and create awareness 

of physical activity 

resources 

Joint use agreements may not 

be enough to encourage the use 

of facilities (e.g., school gym) by 

communities that have gone years 

without access to such resources 

beyond normal business hours. 

• Use educational initiatives, social media, and 

partners to increase awareness of existing facilities 

that are now available to the community. 

• Encourage use by involving residents in developing 

programs (e.g., dance classes, walking clubs) that 

are culturally and age appropriate. 

• Assess user activity regularly to ensure residents’ 

needs are met and multiple users (e.g., the elderly, 

people with disabilities, young girls) benefit from 

the resource. 

EQUITABLE 

ACCESS 

Support equitable 

access to parks and 

open spaces 

The physical activity opportunities 

created by joint use agreements 

may mask the need for more 

permanent physical activity 

resources (e.g., parks), particularly 

in underserved communities. 

• Identify inequities in physical activity resources 

by conducting an assessment of the distribution, 

hours, and pricing of such resources. 

• Understand decision-making processes for 

physical activity resource allocation. 

• Work with partners to examine additional 

strategies to increase options for physical activity 

in communities with the greatest need and ensure 

options accommodate differing levels of mobility 

(e.g., older adults, people in wheelchairs). 

cdc.gov/healthequityguide 76
 

 

 

 

 

 

 

 

 

 

 

 

Build the Team: Partnership for Success 

Successful efforts to implement joint use agreements depend on bringing a diverse set of partners to the 

table early, consistently, and authentically. These partners may include the following: 

• Area Agencies on Aging • Law enforcement 

• Community-based organizations such as Boys • Land trusts or conservancies 

and Girls Club, sports associations, YMCA, Boy • Organizations serving populations experiencing Scouts, Girl Scouts health inequities 

• Community members (of diverse abilities, ages, • Public agencies, including public health, parks cultures, gender, income levels, race/ethnicity, and recreation, housing authority, libraries and sexual orientation) 

• School districts, universities, and • Custodians community colleges 

• Faith-based organizations • Union leaders 

• Health care systems, hospitals, community 

clinics, and health care providers 

HEALTH EQUITY IN ACTION 

Beyond Conventional Joint Use: Farmers’ Market and Trails in Public 

Housing Communities 

San Antonio, TX 

The San Antonio Metropolitan Health District 

(SAMHD) was not afraid to “be bold, and try 

new things.” It teamed up with the San Antonio 

Housing Authority (SAHA)—the landlord for 70 

different public housing communities—to think 

creatively about using existing resources to create 

opportunities for low-income children, adults, 

elderly residents, and those with disabilities to 

be healthy. The results of a community health 

assessment revealed that SAHA residents were 

already well aware that a healthier diet and more 

physical activity would improve their health, but 

they did not have access to fresh produce or a 

safe place to be active. 

Moving beyond the conventional idea of a 

joint use agreement, SAHA took advantage 

of its unique position to provide the space 

and infrastructure that could nurture ideas for 

improving health. In response to residents’ 

identified needs, the partnership initiated an 

effort to develop walking trails on five SAHA 

sites. This project benefits not only residents 

living in public housing, but the neighboring 

community as well. To address concerns about 

the availability of healthy foods, the partnership 

collaborated with the San Antonio Food Bank to 

successfully establish a farmers’ market in one of 

the public housing communities. SAHA residents 

felt strongly that it should be easily accessible 

and located where they live. This muchneeded farmers’ market now provides access 

to affordable, healthy fruits and vegetables in a 

neighborhood that lacks a grocery store. 

Through this joint use partnership with the 

housing authority, SAMHD was able to directly 

reach residents who were most in need. These 

efforts were supported by CDC’s Communities 

Putting Prevention to Work program. 

cdc.gov/healthequityguide 77
 

 

HEALTH EQUITY IN ACTION 

Using a School Playground as a 

Community Resource 

Santa Ana, CA 

Santa Ana is a community with a 

predominantly Latino, low-income 

population that faces high rates of chronic disease, 

including diabetes.187,188 The city has only one acre of 

parks per 1,000 Santa Ana residents, leaving little open 

space for much-needed recreation.187,188 Many of the few 

existing parks are small, not within walking distance of 

residential neighborhoods, and perceived as places that 

attract crime. 

Working with residents and with support from the 

California Endowment, Latino Health Access (LHA) 

pursued a community access agreement at the 

neighborhood Roosevelt Elementary School, which 

was accessible and familiar to residents. Joint use 

agreements allowed community residents to use school 

grounds outside of school hours. However, existing 

agreements did not provide free access to recreational 

spaces to the community at large. They primarily 

accommodated sports leagues, most of which required 

a fee. For most residents living below the poverty line, 

these programs were not a viable option. LHA and 

residents were able to establish a community access 

agreement at Roosevelt in partnership with the Santa 

Ana Unified School District so that everyone in the 

community, not just those who could pay, gained free 

access to recreational space. As LHA staff member 

Nancy Mejia put it, “We are creating a more equitable 

environment by providing physical activity access for 

the whole community.” 

Community engagement was central to this success. 

LHA led parent focus groups to identify programming 

needs, resulting in ideas such as martial arts classes 

and art workshops. Parent feedback underscored the 

importance of opening the school on weekends to 

ensure a majority of residents could use the space. A 

community resident board led the project, bringing 

awareness to the new space and actively engaging other 

community members in activities, such as a walking 

audit around the school, skill building, and a driver safety 

Children playing in an open schoolyard in central Santa Ana, CA. 

Photo Courtesy of Latino Health Access. 

educational initiative. The success of the project 

motivated the city and the school district to 

jointly apply for state funding that could provide 

a community center at Roosevelt Elementary. 

The City was awarded $5 million from California 

Prop 84 funds for the construction of a 10,000 

square-foot community center at Roosevelt 

Elementary. The site serves as a best-practice 

model that could open other schoolyards in 

Santa Ana—providing even more physical activity 

opportunities for everyone in the community. 

cdc.gov/healthequityguide 78
 

 

 

SAFE AND ACCESSIBLE STREETS FOR ALL USERS
�

STREET INFRASTRUCTURE AND TRANSPORTATION STRATEGIES MAY INCLUDE COMPLETE 

STREETS POLICIES, SAFE ROUTES TO SCHOOL POLICIES AND PROGRAMS, AND COMMUNITY 

DESIGN STANDARDS. THESE STRATEGIES CAN HELP ENSURE THAT STREETS ARE ROUTINELY 

DESIGNED, MODIFIED, AND UPDATED TO SUPPORT ALL FORMS OF TRANSPORT, INCLUDING 

ACTIVE TRANSPORT. ACTIVE TRANSPORTATION INCLUDES MODES OF HUMAN POWERED 

TRANSPORTATION SUCH AS WALKING, BIKING, AND USING A WHEELCHAIR. 

MAKE THE CASE: 

Why Is This A Health Equity Issue? 

The issues below highlight the need for street infrastructure and 

transportation strategies that advance health equity: 

• Inadequate Infrastructure for Active Transportation Exists in 

Many Low-Income Communities and Communities of Color: 

Low-income communities and communities of color have 

been found to have poorly maintained sidewalk and street 

infrastructure, higher rates of crime, and increased dangers 

from traffic.174,175 These barriers may discourage some residents 

from engaging in active transportation or make it difficult and 

unsafe for those that depend on such infrastructure. 

• Challenges for Active Transportation Exists in Many Rural 

Communities: Rural communities, including rural tribal lands, 

may experience unique infrastructure inequities. These 

communities may have less pedestrian and bicycling plans and 

infrastructure than urban communities,189 and rural roads are 

some of the most dangerous for pedestrians.190 Additionally, 

the long distances between key institutions/settings may 

present challenges to active transportation. 

• Street Design May Neglect Users with Special Needs: 

There are a variety of potential users to consider in street 

infrastructure and transportation strategies (e.g., the elderly, 

those with a disability, children). For example, older adults 

often have difficulty navigating busy, traffic-heavy roads, areas 

with obstructed or difficult to read signage, and inadequate 

sidewalks.177,179,191 Significant barriers may also exist for people 

with strollers and people with disabilities (e.g., those with 

hearing and vision impairments, those using wheelchairs). 

cdc.gov/healthequityguide 79
 

 

 

 

 

 

 

 

 

 

 

Design and Implement with Health Equity in Mind 

To maximize health impact and advance health equity, consider these factors and others when designing, 

implementing, and evaluating street infrastructure and transportation strategies: 

KEY FACTORS	� BARRIERS OR UNINTENDED OPPORTUNITIES TO MAXIMIZE IMPACT 

CONSEQUENCES 

COMMUNITY 

AWARENESS & 

INVOLVEMENT 

Encourage 

community 

participation and 

leadership 

Community members may face 

barriers (e.g., language, time 

constraints, lack of transportation) 

that prevent them from being 

engaged in infrastructure and 

transportation planning processes. 

• Organize events (e.g., walk and roll audits) to 

increase awareness of and participation in planning 

processes among underserved communities. 

• Work with partners to address barriers to 

participation (e.g., provide venues for input at 

convenient times and locations, hold forums in 

prevalent languages or with interpreters, provide 

childcare if needed). 

• Engage representatives from organizations who are 

trusted by underserved populations to commit to 

long-term participation in planning processes. 

INCLUSIVE 

DECISION 

MAKING & 

DESIGN 

Ensure decision 

processes 

accommodate people 

with special needs 

People with special needs, such 

as the elderly and people with 

disabilities, may be overlooked 

in the design and implementation 

of street infrastructure and 

transportation strategies. 

• Work with transportation planners to engage 

people with special needs in planning and 

implementation processes. 

• Encourage transportation planners to include 

guidelines and strategies developed specifically 

for people with special needs. 

• Use inclusive language when discussing such 

strategies (e.g., “walk, bike, and roll” has been used 

to include those in wheelchairs). 

RESOURCE 

LIMITATIONS 

Find ways to address 

funding limitations for 

street improvements 

in underserved 

communities 

Funding may not be available 

for street improvements, 

particularly in underserved 

communities. Additionally, 

residents of these communities 

may lack the time and resources 

to apply for funding that 

addresses infrastructure. 

• Leverage existing funds to make necessary 

improvements and enhancements (e.g., incorporate 

street improvements into routine road maintenance 

procedures). 

• Provide technical support and training to 

underserved communities to enhance their capacity 

to apply for infrastructure funding. 

• When evaluating proposals for funding, use criteria 

that prioritize communities in greatest need. 

DISPLACEMENT 

Account for 

the potential 

displacement effects 

of street improvement 

strategies 

When a community becomes 

a popular place to walk, bike, 

or use other modes of active 

transportation safely, local 

businesses may benefit. A possible 

result is that property values may 

increase and current residents may 

be displaced if they are no longer 

able to afford living there. 

• Conduct an assessment (e.g., health impact 

assessment) to examine the possibility of 

displacement with all street improvement policies. 

• Utilize supportive mechanisms and community 

benefits agreements (e.g., affordable housing 

protections, local hiring ordinances) to ensure 

current residents are not displaced and can benefit 

from infrastructure improvements. 

(Also see Neighborhood Development that Connects Community Resources to Transit on page 96) 

cdc.gov/healthequityguide 80
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Build the Team: Partnership for Success 

Successful efforts to implement street infrastructure and active transportation strategies depend on strong 

partnerships that bring a diverse set of partners to the table early, consistently, and authentically. These 

partners may include the following: 

• Area Agencies on Aging 

• Community development, revitalization, and 

redevelopment agencies and organizations 

• Community members (of diverse abilities, ages, 

cultures, gender, income levels, race/ethnicity, 

and sexual orientation) 

• Environmental and climate change groups 

• Leaders and community champions from 

multiple sectors 

• Local transportation planning department 

HEALTH EQUITY IN ACTION
�

Creating Safe Routes in a Rural Community 

Sault Ste. Marie, MI 

The service area of the Sault Ste. Marie Tribe of 

Chippewa Indians covers seven rural counties in 

Michigan’s Eastern Upper Peninsula. These counties 

have higher percentages of low-income populations 

than other places in the state. Limited infrastructure 

options often force residents who live in tribal 

housing to drive to local stores, schools, childcare, 

and employment, even though these resources are 

within walking or biking distance. Rising gas prices 

coupled with limited household incomes prompted 

the Sault Tribe Community Health Program, with 

support from the CDC’s Strategic Alliance for Health 

program, to explore infrastructure improvements 

that would support active transportation. 

The Sault Tribe’s Strategic Alliance for Health Project 

staff and coalition members conducted walking 

audits in tribal housing, as well as the broader 

community. Pictures taken by community members 

illustrated the need for bicycle and pedestrian 

improvements. The presentations were effective 

• Organizations serving populations experiencing 

health inequities 

• Program evaluators 

• Public health agencies 

• Public Works Department 

• School districts, universities, and 

community colleges 

• Transit agencies 

• Transportation organizations 

• Zoning and Planning organizations 

in educating community stakeholders about the 

need for pedestrian and bicycle facilities, resulting in 

construction of a sidewalk connecting tribal housing 

in one community to a major employment center. 

In another neighborhood, a need was identified 

for a midblock crossing near a childcare center to 

allow caregivers to take young children on walks 

during the day. The Strategic Alliance for Health 

Project also facilitated a partnership between tribal 

transportation planners and the City of St. Ignace to 

invest in sidewalk improvements that will connect 

housing to a nearby high school athletic field. 

Key partnerships among tribal transportation 

planners, tribal housing authority, local government, 

and school systems fostered success. These 

partnerships were instrumental in implementing 

strategies that will support the creation of complete 

streets in five communities and in the seven-county 

region, focus on safe bicycle and pedestrian projects 

in the regional transportation plans, and address 

health and safety needs of all residents. 

cdc.gov/healthequityguide 81
 

HEALTH EQUITY IN ACTION 

Transportation Framework Supports 

Health Equity and Sustainability 

Multnomah County, OR 

When Multnomah County Health Department staff 

realized the tremendous impact of transportation 

decisions on the health of Oregon’s residents, they 

wanted to get involved. They wanted to ensure 

transportation projects would contribute to—not 

detract from—their health and equity goals. With 

funding from CDC's Communities Putting Prevention 

to Work program, the health department leveraged 

their relationships with local transportation leaders 

and other community-based organizations and began 

working with Upstream Public Health (a Portlandbased public health policy organization), the City of 

Portland Bureau of Transportation, and the North 

American Sustainable Transportation Council. One 

goal of the cross-sector partnership was to create a 

system to ensure health, multimodal safety, and equity 

outcomes are improved in the planning, analysis, and 

operation of transportation plans and projects. 

In 2010, the North American Sustainable 

Transportation Council developed the Sustainable 

Transportation Analysis and Rating System (STARS) 

pilot project application manual. STARS is a 

framework for developing and rating transportation 

projects, plans, and programs. It is a performancebased system with a multimodal focus that allows 

planners to compare and improve performance across 

all modal strategies. The STARS project manual 

currently consists of 12 core credits that encompass 

the “triple bottom line,” also known as the “three Ps” 

of access (people), climate and energy (planet), and 

cost effectiveness (prosperity). Projects that achieve 

at least nine of the 12 core credits are qualified for 

STARS certification. Through Multnomah County’s 

collaborative effort, three new STARS credits have 

been developed to increase the likelihood that 

transportation projects improve key health, safety, 

and equity criteria. 

With health equity as a driving principle, STARS gives 

credit for meaningful engagement of the communities 

most affected by the transportation project. Focusing 

Infrastructure improvements on the Hawthorne Bridge in 

Multnomah County make safe, sustainable, and equitable 

transportation options available to all users. Photo Courtesy 

of Greg Raisman 

on meaningful engagement ensures residents 

have a say in how transportation projects are 

planned and implemented. Credits are also 

awarded to projects that are planned so that 

transportation-disadvantaged communities gain 

improved access to meet daily needs and are not 

burdened disproportionately. Plans and projects 

that earn safety, health, and equity 

credits take one step closer to becoming STARS 

certified, providing an incentive for transportation 

planners and project managers to integrate 

health, safety, and equity into their work. 

Certified projects may be prioritized for 

government funding. Communities across the 

country can use STARS to ensure that their own 

transportation projects and plans include health 

and multimodal safety, while maximizing efforts 

to achieve equitable outcomes. 

cdc.gov/healthequityguide 82
 

 

TRAILS AND PATHWAYS TO ENHANCE RECREATION 

AND ACTIVE TRANSPORTATION 

TRAILS AND PATHWAYS CAN PROVIDE A VENUE FOR RECREATIONAL PHYSICAL ACTIVITY, 

AS WELL AS ACTIVE TRANSPORTATION (E.G., WALKING, BIKING, USING WHEELCHAIRS) TO 

WORK, SCHOOL, AND COMMUNITY RESOURCES. 

MAKE THE CASE: 

Why Is This A Health Equity Issue? 

The issues below highlight the need for 

trail and pathway strategies that advance 

health equity: 

• Limited Access to Physical Activity Resources in 

Many Underserved Communities: Communities with 

higher poverty rates and higher proportions of people 

of color have been found to have few physical activity 

resources.176,192 Additionally, rural communities may have 

less access to resources such as recreational facilities 

and sidewalks.193 

• Barriers to the Use of Trails and Pathways May Exist 

for Some Population Groups: Trail use may be deterred 

by litter issues, excessive noise from the street, the 

presence of tunnels, safety concerns, and vegetation 

density.194 Additionally, trail use may be challenging 

for older adults and people with disabilities if trails are 

not designed to consider their needs. For example, 

barriers to physical activity among these populations 

may include physical obstacles (e.g., narrow paths, low 

lighting, uneven or soft surfaces that make wheelchair 

use more difficult), logistical challenges (e.g., lack of 

transportation to facilities),195 and poor visibility 

(e.g., unmarked entry points to trails). 

cdc.gov/healthequityguide 83
 

 

 

 

 

 

 

 

 

 

 

 

Design and Implement with Health Equity in Mind 

To maximize health impact and advance health equity, consider these factors and others when designing, 

implementing, and evaluating trail and pathway strategies: 

KEY FACTORS BARRIERS OR UNINTENDED OPPORTUNITIES TO MAXIMIZE IMPACT 

CONSEQUENCES 

RESOURCE 

LIMITATIONS 

Pursue creative 

financing strategies 

and enhance existing 

trails and pathways 

in underserved 

communities 

Developing a new trail or pathway 

may be unrealistic in certain 

communities given the complexity 

of the project, financial resources 

required, and geographic 

constraints.196,197 

• Leverage land trusts to navigate the financing and 

real estate aspects of securing land for public good. 

• Pursue public-private partnerships and creative 

financing strategies, (e.g., railbanking, local 

finance measures, block grants) to support 

trail development. 

• Expand or improve existing trails, sidewalks, or paths 

when resources and/or physical space are limited. 

COMMUNITY 

AWARENESS & 

INVOLVEMENT 

Engage residents 

in planning and 

monitoring decisions 

relevant to trails 

and pathways 

Participation in local and 

regional planning processes 

can be a challenge due to time, 

logistical barriers, and the 

technical knowledge required 

for full participation. 

• Partner with trusted organizations to identify 

residents to serve as community liaisons in 

planning processes. 

• Train community liaisons to serve as spokespeople, 

monitor the processes, inform others about input 

opportunities, and collect data as needed. 

• Conduct ongoing maintenance (e.g., clear 

SAFETY vegetation and trash, remove graffiti) to promote 

safety of paths. 

Improve or 

maintain safety to 

maximize trail usage 

Real or perceived concerns 

about safety may deter people 

from using trails and paths. 

• Engage community groups and residents to 

provide long-term trail maintenance. 

in underserved • Use approaches such as Crime Prevention

communities through Environmental Design (CPTED)198 to 

create safer environments. 

SOCIAL 

AND OTHER 

SUPPORTS 

Provide supports that 

enhance trail use 

Residents who have historically 

lacked access may not be aware 

of trails or may need additional 

support to make trail use a part 

of their routine. 

• Develop initiatives to encourage trail use 

(e.g., health education initiatives, physician 

referrals, walking clubs). 

• Partner with local agencies to host events and 

activities that use paths and trails. 

• Partner with local law enforcement to 

promote safety. 

• Enhance existing trails to facilitate access 

between community resources (e.g., housing, 

transit stations, parks, schools, retail centers). 

cdc.gov/healthequityguide 84
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Build the Team: Partnership for Success 

Successful efforts to implement trail and pathway strategies depend on bringing a diverse set of partners to 

the table early, consistently, and authentically. These partnerships may include the following: 

• Area Agencies on Aging 

• Chambers of commerce 

• Community-based 

organizations 

• Community development, 

revitalization, and 

redevelopment agencies 

and organizations 

• Community members (of 

diverse abilities, ages, 

cultures, gender, income 

levels, race/ethnicity, and 

sexual orientation) 

• Faith-based organizations 

HEALTH EQUITY IN ACTION
�

• Health care systems, hospitals, 

community clinics, and health 

care providers 

• Land trusts or conservancies 

• Leaders and community 

champions from multiple sectors 

• Local businesses 

• Local governments 

• Local department of 

transportation 

• Local organizations of those 

with differing abilities 

• Parks and recreation 

department 

• Public health agencies 

• Public Works Department 

• Real estate developers 

• Social services agencies 

• State department of 

conservation 

• State department of natural 

resources 

• State department of 

transportation 

• Zoning and Planning 

organizations 

Trails Upgraded to Better Connect People and Destinations 

Mid-Ohio Valley, WV 

“If you build it, they will come” did not ring true for 

the miles of underutilized trails in rural Mid-Ohio 

Valley, partly because low-income residents lacked 

access to these pathways. This lack of access 

presented a real barrier to active transportation. 

To understand how to promote more trail usage, 

the Mid-Ohio Valley Regional Health Department, 

with support from CDC’s Communities Putting 

Prevention to Work program, conducted mapping 

and community assessments. Results highlighted 

the need for better connectivity between trails and 

desirable destinations, mile markers, and 

informative signage such as kiosks in parks with 

maps of trails denoting wheelchair accessibility 

and level of trail difficulty. 

Capitalizing on the diversity of partner expertise, the 

health department worked with the West Virginia 

Parks and Recreation Department, the Regional 

Council, county commissioners, and others to 

develop a master plan with a strong emphasis on 

improving existing trails. Community coalitions, 

faith-based organizations, and youth organizations 

were also engaged to ensure low-income residents 

were engaged throughout the planning process. 

Community members had a vote in which trail 

improvements were the highest priorities. By May 

2012, the master plan was adopted by five of the six 

counties in Mid-Ohio Valley. 

Strong collaboration and leveraging funds were keys 

to success for implementation and sustainability. 

Local churches granted access to their property 

where portions of the trails crossed. In Pleasants 

County, the health department partnered with the 

Department of Education to connect the county’s 

elementary school track to a nearby community and 

nursing home for public use. Smaller communities 

dealing with budgetary restraints were able to 

leverage Complete Streets policy and transportation 

enhancement efforts for trail improvements. 

cdc.gov/healthequityguide 85
HEALTH EQUITY IN ACTION
�

Community residents in Jefferson County, AL engage in development of the Red Rock Ridge and Valley Trail System Master Plan. 

Photo courtesy of Freshwater Land Trust. 

Trails and Pathways Increase Connectivity for All in Alabama 

Jefferson County, AL 

A mapping assessment showed that many people 

lacked access to places for physical activity in 

Jefferson County—a jurisdiction in Alabama 

with many African American and low-income 

populations. Residents experiencing the highest 

rates of chronic disease and the lowest levels of 

activity live in neighborhoods where connectivity 

to trails and greenways was limited. 

To address this lack of access, Freshwater Land 

Trust (FWLT), a local greenway conservation 

organization teamed up with the Health 

Action Partnership and the Jefferson County 

Department of Health to lead development of 

the Red Rock Ridge and Valley Trail System 

Master Plan. These efforts were supported 

by CDC’s Communities Putting Prevention to 

Work program. Collaborating with established 

community organizations helped to drive the 

project’s success. Churches spread the word to 

congregations about opportunities to be involved 

in planning, and a consulting firm with deep 

community connections facilitated stakeholder 

meetings in the smallest towns in the county. 

Over 40 meetings were held at convenient 

and neutral locations including churches, local 

museums, city halls, and the Civil Rights Institute 

in Birmingham—the largest city in the county. An 

online interactive map provided opportunities to 

participate and add suggestions virtually. 

Over 3,000 residents contributed suggestions 

in the development of the Master Plan, which 

connects more than 200 miles of greenways 

and trails to nearby homes, schools, churches, 

and businesses. Wendy Jackson, Executive 

Director of FWLT underscored the impact of the 

community-driven planning process: “If you want 

to know where people want to walk but there is 

no trail, you have to ask them. There were many 

connections that would not have been made 

if it were not for [community participation].” 

The coalition’s “Our One Mile” planning process 

inspired residents, businesses, and local 

organizations to embrace the Master Plan. 

cdc.gov/healthequityguide 86
 

 

 

 

PHYSICAL ACTIVITY OPPORTUNITIES IN 

SCHOOL, AFTERSCHOOL, AND EARLY CARE 

AND EDUCATION SETTINGS 

PHYSICAL ACTIVITY STRATEGIES FOR CHILDREN AND YOUTH INCLUDE A RANGE OF POLICY 

AND ENVIRONMENTAL IMPROVEMENTS SUCH AS PHYSICAL EDUCATION (PE) REQUIREMENTS, 

PHYSICAL ACTIVITY BREAKS, AND ACTIVE COMMUTING OPTIONS IN SCHOOL, AFTERSCHOOL, 

AND EARLY CARE AND EDUCATION SETTINGS. 

MAKE THE CASE: 

Why Is This A Health Equity Issue? 

The issues below highlight the need for physical activity 

strategies that advance health equity: 

• Opportunities for Physical Activity Outside of School 

Are Limited in Many Underserved Communities: 

Access to affordable, culturally appropriate physical 

activity opportunities outside of school time such 

as gyms, clubs, and recreation facilities is limited in 

under-resourced communities.176,199 Factors such as 

unsafe recreation areas, lack of open space, violence, 

perceptions of violence, inadequate walking and biking 

paths, and dangers from traffic may also play a role in 

discouraging children from physical activity. 

• Many Institutions Have Limited Resources to 

Implement Physical Activity Programming: Even when 

supportive institutional policies are in place, differential 

access to resources can make implementing physical 

activity opportunities a challenge for institutions in lowincome communities. Insufficient funding, inadequate 

or inaccessible recreation facilities and equipment, 

and lack of qualified staff can decrease the ability of 

institutions to offer quality programming.181,200

• Needs Differ Among Children of All Abilities: 

Children with disabilities may have some restrictions that 

limit participation in certain activities. Understanding their 

ability to access equipment, space, and infrastructure is 

essential for promoting physical activity.201 Additionally, 

gender and cultural norms and preferences should be 

considered to ensure the appropriateness of physical 

activity opportunities. 

cdc.gov/healthequityguide 87
 

 

 

 

 

 

 

 

 

 

 

 

 

 

Design and Implement with Health Equity in Mind 

To maximize health impact and advance health equity, consider these factors and others when designing, 

implementing, and evaluating physical activity strategies: 

KEY FACTORS BARRIERS OR UNINTENDED OPPORTUNITIES TO MAXIMIZE IMPACT 

CONSEQUENCES 

EQUITABLE 

IMPLEMENTATION 

& ENFORCEMENT 

Promote equitable 

implementation 

and enforcement 

of physical activity 

programs and policies 

Even if a policy is in place, underresourced settings may have 

difficulty implementing quality 

physical activity improvements and 

policies, resulting in children in these 

settings receiving fewer benefits 

from the programs and policies. 

• Put accountability measures in place to monitor 

and enforce implementation efforts across settings. 

Address the needs of under-resourced institutions. 

• Prioritize professional development, continuing 

education, and training opportunities for staff working 

in underserved communities. 

• Consider allocating technical and financial resources 

to under-resourced settings to implement physical 

activity improvements. 

LIMITED 

RESOURCES 

(STAFF & 

INFRASTRUCTURE) 

Find low-cost and 

creative ways to 

incorporate physical 

activity for all children 

Limited staff, space, and facilities 

may be obstacles to implementing 

physical activity, particularly in 

under-resourced settings.202 

• Partner with nearby schools, public health agencies, 

faith-based organizations, and local businesses to 

locate funding for activities or leverage alternative 

sites for physical activity near the school. 

• Combine resources to hire physical education (PE) 

specialists that rotate to different schools and 

afterschool programs to provide quality instruction 

and help train staff. 

• Explore play activities that require minimal 

equipment or consider integrating physical activity 

into classroom instruction. 

LIMITED 

CAPACITY 

Develop creative 

solutions for small 

and home-based 

childcare facilities to 

prevent undue burden 

Home-based childcare facilities are 

relied on heavily by low-income 

and single-parent families. These 

facilities, along with other small 

childcare facilities, may have 

limited capacity to adequately 

implement or may not be included 

in physical activity program or 

policy requirements. 

• Identify small and home-based childcare providers 

and engage them to help develop feasible physical 

activity practices in these settings. 

• Understand challenges and provide technical 

assistance and continuing education programs to 

build capacity among providers. 

• Promote cost-neutral physical activity strategies 

and find creative ways to leverage existing resources 

in these settings. 

COMMUNITY 

AWARENESS & 

INVOLVEMENT 

Create meaningful 

opportunities for 

parents/guardians 

to engage in 

decision making 

Lack of parent/guardian 

engagement may make it difficult 

for settings to prioritize physical 

activity or have the voluntary 

supports to make improvements. 

Competing responsibilities and 

language needs may also make it 

difficult for some parents/guardians 

to participate in school meetings. 

• Engage parents/guardians and provide leadership 

and decision-making opportunities about wellness 

policies, PE, recess, intramural sports, afterschool 

programs, and other physical activity-related issues. 

• Schedule school forums at convenient times 

and provide additional support, such as language 

interpretation and childcare services to 

maximize participation. 

• Develop feedback tools such as surveys, so families 

can provide input outside of formal meetings. 

cdc.gov/healthequityguide 88
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Build the Team: Partnership for Success 

Successful efforts to implement physical activity strategies in school, afterschool, and early care and 

education settings depend on bringing a diverse set of partners to the table early, consistently, and 

authentically. These partners may include the following: 

• Afterschool providers 

(e.g., Boys and Girls 

Club, YMCA) 

• Childcare centers and provider 

organizations 

(e.g., Head Start) 

• Childcare licensing agencies 

• Community members 

(of diverse abilities, ages, 

cultures, gender, income 

levels, race/ethnicity, and 

sexual orientation) 

HEALTH EQUITY IN ACTION
�

• Faith-based organizations 

• Leaders and community 

champions from 

multiple sectors 

• Organizations serving 

populations experiencing 

health inequities 

• Parent-teacher associations 

and organizations 

• Parks and recreation 

department 

• Public health agencies 

• School districts, universities, 

and community colleges 

• School district administrators, 

teachers, and PE specialists 

• Social service agencies 

• State departments of 

education, particularly 

agencies focused on early 

childhood development 

• Youth development 

organizations 

Volunteer Services Increase Physical Activity in Afterschool Programs
�

California 

With the goal of improving health, educational, 

and social outcomes, Coaching Corps partners 

with low-resourced schools, community 

organizations, and institutions of higher learning 

across California to increase students’ access 

to high-quality sports activities. Coaching 

Corps works directly with these organizations 

to improve afterschool programming and 

coordination among physical education teachers, 

recess supervisors, and afterschool providers 

to ensure that each student engages in quality 

physical activity for at least 60 minutes a day. 

A trained and supportive coach can significantly 

increase the number of students who participate 

in sports activities. Coaching Corps’ previous 

model provided funds to hire sports coaches for 

low-resourced afterschool programs. However, 

once that funding ended, programs were often 

unable to afford coaches and could no longer 

provide these opportunities. 

Recognizing that this model was 

unsustainable, Coaching Corps began 

partnering with local colleges and 

universities to recruit and train college students 

as volunteers. Partnerships with these academic 

institutions enable Coaching Corps to continue 

providing ongoing free support to low-resourced 

schools and afterschool programs. At the same 

time, the student volunteers build leadership 

and technical skills, establish meaningful 

relationships with young people, and give back 

to the community. 

Even with limited staffing and fiscal resources, 

these efforts have been successful in increasing 

physical activity among underserved children 

and youth. Working with the Evelyn and Walter 

Haas Jr. Fund and generous individual donors, 

Coaching Corps has placed nearly 2,500 coaches 

in afterschool programs, reaching nearly 20,000 

students since 2005. 

cdc.gov/healthequityguide 89
HEALTH EQUITY IN ACTION
�

Playworks providing opportunities for physical activity and safe meaningful play in the community. Photo courtesy of Playworks Detroit. 

Playworks: Using Recess as a Place to Play and Be Active 

Detroit, MI 

The long winters in Detroit, coupled with the lack 

of safe places to play, make physical activity during 

the school day challenging. But Playworks Detroit 

has turned these challenges into opportunities. A 

national nonprofit, Playworks partners with lowresource schools in local communities to provide 

organized recess using games that are highly 

adaptable, require few resources, and promote 

positive behavior. In 2010, Playworks Detroit 

was launched to address the activity needs 

of local students, and has since served 18,000 

students. With support from the Robert Wood 

Johnson Foundation and other local foundations, 

corporations and individuals, Playworks is able to 

implement strategies using physical activity and 

safe meaningful play to improve the well-being of 

children in the community. 

Playworks has found ways to use spaces, from 

hallways and parking lots to auditoriums and gyms, 

as places for play. Games that require very few 

pieces of equipment have come in handy for smaller 

spaces. For example, Playworks can make games 

fun and action-packed with as little as a ball, a few 

hula hoops, and a couple of safety cones. 

During recess, Playworks coaches organize stations 

with games such as tag, four square, and kickball, 

which can be modified to include students of 

all abilities. Playworks coaches model positive 

behavior, and this creates a shared understanding 

among students. This shared understanding leads 

to fewer conflicts on the playground and more 

productive classroom time. 

In addition to working in schools, Playworks 

Detroit plays with the community once a month 

by partnering with local organizations, the police 

department, and the mayor’s office to host events 

such as Recess Days. During one Recess Day, 

Detroit’s mayor joined hundreds of students in 

downtown Detroit as they learned how to play 

safely while having fun. “Getting kids to be 

physically active is a good place to start. Then 

you can begin a conversation on how do we as a 

community create more safe places to play,” says 

Jeannine Gant, Executive Director of Playworks 

Detroit. By providing trained coaches, working with 

a wide variety of partners, and demonstrating that 

children can play anywhere if they are supported, 

Playworks Detroit is getting students and the larger 

Detroit community to play again. 

cdc.gov/healthequityguide 90
 

 

 

 

 

 

NEIGHBORHOOD DEVELOPMENT THAT CONNECTS 

COMMUNITY RESOURCES TO TRANSIT 

TRANSIT-ORIENTED DEVELOPMENT (TOD) AND MIXED-USE ZONING ARE TWO INTERRELATED STRATEGIES 

THAT CAN FACILITATE AVAILABILITY OF AFFORDABLE HOUSING CLOSE TO PUBLIC TRANSPORTATION, 

PHYSICAL ACTIVITY INFRASTRUCTURE, HEALTHY FOOD RETAIL, AND OTHER HEALTH-PROMOTING 

SERVICES AND COMMUNITY INSTITUTIONS. THESE STRATEGIES CAN ALSO HELP FACILITATE 

OPPORTUNITIES FOR ACTIVE TRANSPORT SUCH AS WALKING, BIKING, AND USING A WHEELCHAIR. 

MAKE THE CASE: 

Why Is This A Health Equity Issue? 

The issues below highlight the need for TOD and mixed-use 

zoning strategies that advance health equity: 

• Accessible and Affordable Public Transit Is a Need for Many 

Underserved Populations: Public transit may be a necessity 

for individuals who cannot afford the cost of an automobile 

and the associated owning, operating, and maintenance 

expenses. Additionally, individuals with a low-income, older 

adults, and people with disabilities may also need to rely heavily 

on public transportation203,204 for reaching services, employment, 

and recreation. 

• Negative Consequences of Zoning Strategies May Exist 

in Underserved Communities: Over time, zoning and other 

factors have contributed to the differential distribution of 

community resources (e.g., healthy food and physical activity 

opportunities), and ultimately health inequities.151,205 Zoning 

strategies such as transit-oriented development may also 

lead to changes in neighborhood demographics and housing 

values. Such changes may lead to the displacement of some 

populations, possibly placing them further away from quality 

employment opportunities, schools,203 and healthpromoting resources such as healthy food retail and parks. 

• Rural Communities Face Unique Issues Related to 

Transportation and Access to Goods and Services: 

Many residents in rural areas frequently lack or have 

limited access to public transportation options.206 Further, 

long commute times, infrequent service, cost, and lack of 

infrastructure to facilitate transit use may present additional 

barriers to reliable transportation for rural public transit users. 

Note: As many land use and zoning strategies fall in the purview of other sectors, 

public health agencies should work with appropriate partners when considering 

such strategies. 

cdc.gov/healthequityguide 91
 

 

 

 

 

 

 

 

 

 

 

 

 

 

Design and Implement with Health Equity in Mind 

To maximize health impact and advance health equity, consider these factors and others when designing, 

implementing, and evaluating transit-oriented development and mixed-use zoning strategies: 

KEY FACTORS 

INCLUSIVE 

ANALYSIS 

Establish an inclusive 

process designed 

to assess health 

effects and define 

local solutions 

COMMUNITY 

AWARENESS & 

INVOLVEMENT 

Build capacity and 

promote engagement 

of people who are 

typically absent from 

planning processes 

DISPLACEMENT 

Account for potential 

displacement effects 

of TOD and mixed-use 

zoning strategies 

TRANSPORTATION 

NEEDS 

Consider TOD and mixeduse zoning strategies in 

transportation networks 

that serve all transit users 

EXISTING 

OPPORTUNITIES 

Expand TOD and 

mixed-use zoning 

efforts to address social 

determinants of health 

BARRIERS OR UNINTENDED 

CONSEQUENCES 

Zoning and transit projects 

may move ahead without a 

clear understanding of potential 

outcomes for health and 

health inequities. 

Underserved residents may be left 

out of planning processes,207 which 

may result in development decisions 

that fail to encompass diverse 

perspectives. Planning processes 

can also be time consuming and 

technical,208 which may present a 

barrier to resident participation. 

Transit investments may drive up 

median area income, housing values, 

and rents. A possible result of such 

changes is that existing residents 

and small business owners may no 

longer be able to afford living or 

doing business there. 

Many TOD efforts are centered on 

rail with little focus on bus transit 

or bus rapid transit. Rail projects 

can be resource-intensive, may often 

serve more affluent populations, 

and could divert funds from bus 

transit upgrades.210,211

Transit-oriented development and 

mixed-use zoning may not explicitly 

address community conditions like 

access to healthy food and physical 

activity opportunities, or other 

social determinants such as safety, 

jobs, and housing. 

OPPORTUNITIES TO MAXIMIZE IMPACT 

• Use health and equity impact assessments to 

identify potential unintended negative consequences 

of all community improvement efforts. 

• Engage residents in the assessment process and 

raise awareness of potential health effects of proposed 

plans and any alternatives. 

• Use assessment process to increase transparency 

in decision-making and improve communication 

between partners. 

• Diversify leadership on boards and commissions 

to ensure multiple perspectives in decisionmaking processes. 

• Cultivate resident understanding, leadership, 

and decision-making through training programs, 

guided reviews of plans, neighborhood scans, and 

mapping activities. 

• Ensure public input is inclusive, timely, and 

representative of community experiences. 

• Conduct an assessment (e.g., health impact 

assessment) to examine the possibility of 

displacement with TOD and mixed-use 

zoning strategies. 

• Utilize supportive mechanisms and community 

benefits agreements (e.g., affordable housing 

protection, local hiring ordinances, tax credits) to 

ensure current residents are not displaced and can 

benefit from improvements.209

• Consider TOD and mixed-use zoning strategies 

near transit hubs, transit connections, and 

intersections that are served by multiple bus 

routes in communities where rail is limited. 

• Where possible, align development and transit 

with the places people need to travel 

(e.g., housing, employment, services). 

• Use TOD and mixed-use strategies to provide 

incentives to businesses that could provide healthy 

food options, and to create environments that 

support physical activity. 

• Consider limiting aspects of nuisance businesses 

(e.g., density, location) which may affect quality of 

life, increase safety concerns, and be more common 

in low-income neighborhoods. 

• Consider ways to create access to living wage 

employment through compact zoning and 

development that connects residents to 

employment opportunities. 

• Employ techniques such as Crime Prevention through

Environmental Design198 to address safety. 

cdc.gov/healthequityguide 92
 

 

 

 

 

 

 

 

 

 

 

 

 

 

Build the Team: Partnership for Success 

Successful efforts to implement transit-oriented development and mixed-use zoning strategies depend on 

bringing a diverse set of partners to the table early, consistently, and authentically. These partners may 

include the following: 

• Area Agencies on Aging 

• Community-based organizations 

• Community development corporations 

• Community finance institutions 

• Community members and residents affected 

by transit investments (of diverse abilities, ages, 

cultures, gender, income levels, race/ethnicity, 

and sexual orientation) 

• Developers 

HEALTH EQUITY IN ACTION 

• Funders 

• Local businesses 

• Local, state, and regional governments 

• Metropolitan planning organizations 

• Public health agencies 

• Public Works Department 

• Regional transit agencies 

• Zoning and Planning organizations 

Addressing Equitable Development through a Health Impact Assessment of a Zoning Code
�

Baltimore, MD 

Many Baltimore neighborhoods have higher rates 

of homicide and chronic disease than the rest of 

Maryland.212 The investigators of the Zoning for 

a Healthy Baltimore Health Impact Assessment 

(HIA) argued that truly tackling health disparities in 

Baltimore required addressing factors in the zoning 

code related to crime and violence, with the goal 

of enabling walkable, mixed-use neighborhoods. 

They made the case that environmental changes to 

address safety concerns could increase walking and 

activity for neighborhood residents. 

The Public Health Working Group at Johns Hopkins 

University and the Baltimore City Health Department 

conducted a HIA funded by Robert Wood Johnson 

Foundation, in order to address the intersection of 

urban planning and public health by emphasizing that 

zoning can influence health. The HIA was used to 

identify which elements of the Baltimore zoning code 

(in its first rewrite since 1971) might promote or inhibit 

health—both generally and related to childhood 

obesity in particular. 

The HIA began with a detailed literature review. 

One of the several findings was that the density of 

alcohol outlets in an area is linked to increased rates 

of violence. Several steps were already being taken 

to improve walkability and food access, however, 

the HIA helped draw attention to the role alcohol 

outlets might play in affecting neighborhood health. 

An evaluation of how the zoning regulations might 

change, reviews of the scientific literature, and 

interviews with stakeholders and urban health 

experts made it clear: addressing the number and 

location of alcohol outlets in certain neighborhoods 

could begin to shift perceptions of safety and impact 

physical activity rates to reduce the wide health 

disparities in Baltimore. 

By using neighborhood health profiles, violent 

crime statistics, and alcohol outlet location data, 

the HIA team was able to demonstrate the need 

for additional consideration of alcohol outlet 

locations in the city’s rewrite of the zoning code. 

Working with a variety of stakeholders including the 

departments of Law, Planning, and Health, the HIA 

team developed recommendations to address the 

density of alcohol outlets. Since the development of 

the recommendations, Baltimore City has revised its 

zoning code to incorporate dispersal standards and 

other strategies for new and existing alcohol outlets. 

cdc.gov/healthequityguide 93
HEALTH EQUITY IN ACTION
�

Fruitvale Arch Monument at the Fruitvale Transit Village which now connects community residents to housing, services, and other resources. 

Photo Courtesy of Brandon Moore. 

Job Opportunities and Services Come to a Neighborhood via Transit-Oriented Development 

Oakland, CA 

In the early 1990s, Bay Area Rapid Transit 

(BART) announced a plan to build a massive 

parking garage near the Fruitvale transit station 

in Oakland. The proposed garage would have 

increased single-occupant automobile traffic and 

isolated the Fruitvale neighborhood, a largely 

immigrant community of households living 

below the federal poverty level. In response, 

residents worked closely with The Unity Council, 

a community development corporation that helps 

families and individuals build wealth and assets, to 

develop an alternative plan for the Fruitvale Transit 

Village. This village was one of the first transitoriented developments in the United States. 

The new transit village development provides 

housing, services, and jobs to low-income 

residents in a central location. The Unity Council 

leveraged funding from several federal, state, local 

and private sources. The Council also partnered 

with BART and the City of Oakland to address 

concerns regarding public safety, walkability, 

affordable housing, and economic development. 

Businesses and organizations in the 

Fruitvale Transit Village now cater to 

residents, commuters, and visitors. 

The Village has a daycare center, clinic, 

high school, senior center, library, and 

sit-down restaurants. It also hosts a weekly 

farmers’ market and one of the largest Day of the 

Dead festivals in the nation. Five hundred jobs 

are provided onsite and several thousand people 

receive services in the Village each day. 

The Fruitvale Transit Village has become a safe 

haven, bringing generations—preschoolers, 

teenagers, and older adults—together and 

fostering a collective sense of respect for the 

community space. The Unity Council has begun 

the next phase of the project: more housing and 

a large community center that will be open seven 

days a week, with culturally appropriate youthfocused programming at low or no cost. Careful 

planning has helped protect against displacement 

of residents, encouraging a flourishing mixedincome neighborhood through job opportunities, 

services, and affordable housing. 

cdc.gov/healthequityguide 94
 

 

PREVENTING VIOLENCE
�

PREVENTING COMMUNITY VIOLENCE IS CRITICAL TO CHRONIC DISEASE PREVENTION AS VIOLENCE 

(REAL OR PERCEIVED) MAY BE A BARRIER TO HEALTHY BEHAVIORS SUCH AS WALKING AND BICYCLING, 

USING PARKS AND RECREATIONAL SPACES, AND ACCESSING HEALTHY FOOD OUTLETS. PREVENTING 

COMMUNITY VIOLENCE REQUIRES BRINGING TOGETHER MULTI-SECTOR PARTNERS AND THE 

COMMUNITY TO SELECT AND IMPLEMENT POLICY, ENVIRONMENTAL, AND STRUCTURAL INTERVENTIONS 

BASED ON THE BEST AVAILABLE EVIDENCE AND THE COMMUNITY CONTEXT. SUCH INTERVENTIONS 

MAY INCLUDE COMMUNITY ECONOMIC DEVELOPMENT STRATEGIES (E.G., BUSINESS IMPROVEMENT 

DISTRICTS213), BUILT ENVIRONMENT STRATEGIES (E.G., CRIME PREVENTION THROUGH ENVIRONMENTAL 

DESIGN214-216), AND STREET OUTREACH AND COMMUNITY MOBILIZATION (E.G., CURE VIOLENCE – 

FORMERLY KNOWN AS CEASEFIRE CHICAGO217). 

MAKE THE CASE: 

Why Is This A Health Equity Issue? 

The issues listed highlight the need for violence prevention 

strategies that advance health equity: 

• Some Communities Have A Disproportionate Burden of 

Violence: Inequities in violence-related outcomes (e.g., 

homicides, injuries, incarceration) are related to a variety 

of systemic issues.218,219 While violence is a reality in all 

communities, some communities and groups are far more 

exposed to diminished neighborhood conditions (e.g. 

neighborhood poverty, high alcohol outlet density, social 

isolation) that give rise to violence, and violence can thus 

become the norm.”220,221 

• A Disproportionate Burden of Violence Exists for Some 

Youth of Color: The risk of experiencing violence varies 

significantly by race and ethnicity. For example, in 2010, 

among 10-to-24 year-olds, homicide was the leading 

cause of death for African Americans, second leading 

cause of death for Hispanics, third leading cause of death 

for American Indians/Alaska Natives, and the fourth 

leading cause of death among Asian/Pacific Islanders 

and non-Hispanic Whites.222 The disparity in ranges of 

violence extend beyond homicide, as a higher percentage 

of African American/Black high school students (40%) 

and Hispanic (37%) youth report that they have been in 

at least one physical fight in the previous year than nonHispanic White students (29%).223 

cdc.gov/healthequityguide 95
 

 

 

 

 

 

 

 

 

 

 

 

 

Design and Implement with Health Equity in Mind 

To maximize health impact and advance health equity, consider these factors and others when designing, 

implementing, and evaluating strategies to prevent violence: 

OPPORTUNITIES TO MAXIMIZE IMPACT 

• Build multi-sector partnerships to change 

institutional practices that have a disproportionate 

effect on certain population groups. 

• Ensure school discipline practices are consistent 

for all students. 

• Encourage positive media coverage of young 

people in communities affected by violence. 

• Address policies and practices in the criminal justice 

system that result in higher rates of involvement in 

the criminal justice system for young men of color. 

• Learn about and partner with agencies 

with experience in community economic 

development strategies. 

• Create opportunities to support business 

investments and community development to create 

an economically viable community. 

• Consider changing the physical characteristics 

of housing, schools, and community areas to 

improve perceived and actual safety, and to reduce 

opportunities for crime and violence. 

• Consider Crime Prevention through Environmental 

Design (CPTED)198 strategies (e.g., improved lighting, 

unobstructed sights lines, improved landscaping, 

graffiti removal, increased video and natural 

surveillance) to address crime and safety concerns. 

• Partner with law enforcement to improve safety 

and increase spaces for social interaction. 

• Provide opportunities for residents to form positive 

relationships and contribute to the well-being of 

the community. 

• Engage youth in activities, since they are 

particularly vulnerable to experiencing negative 

health and safety outcomes associated with a 

disorganized community. 

• Consider street outreach and community 

mobilization strategies to promote positive 

interactions. 

KEY FACTORS 

DIVERSE 

PARTNERSHIPS 

Work with systems 

that have been part 

of the Pipeline* to get 

to different outcomes 

ECONOMIC 

OPPORTUNITY 

Promote economic 

opportunities 

and growth to 

build viable and 

stable communities 

SAFE SPACES 

Create a safe 

physical environment 

and provide spaces 

to strengthen 

social relationships 

SOCIAL 

COHESION 

Facilitate the social 

cohesion of the 

community 

BARRIERS OR UNINTENDED 

CONSEQUENCES 

Racism, discrimination, and stigma 

may exist in many institutional 

practices, and may perpetuate 

prejudicial treatment. 

For example, practices related to 

school discipline, media portrayal, 

and the criminal justice system 

might foster differential outcomes 

for youth of color. 

Limited economic and occupation 

opportunities may drive residents 

away, creating instability and a 

higher concentration of 

low-income residents. These 

factors may increase the risk for 

youth to resort to violence.224 

Visible signs of disorder and 

neglect in a community make it 

more appealing as a venue for 

crime and violence. 

The risk of violence is higher 

in communities where individuals, 

groups, and organizations do 

not interact with each other in 

positive ways.225,226 

* The Children’s Defense Fund has named the trajectory that results in disproportionate incarceration rates for African American and Latino 

males ‘The Cradle to Prison Pipeline’. http://www.childrensdefense.org/programs-campaigns/cradle-to-prison-pipeline/ 

cdc.gov/healthequityguide 96
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

KEY FACTORS 

COMMUNITY 

AWARENESS & 

INVOLVEMENT 

Engage community 

members and local 

organizations in a 

meaningful way 

RESOURCE 

LIMITATIONS 

Integrate efforts to 

prevent violence 

within multiple 

community initiatives 

BARRIERS OR UNINTENDED 

CONSEQUENCES 

Individuals most affected by 

violence may not be included 

in violence prevention efforts in 

meaningful ways. Additionally, 

resources directed to the violence 

prevention efforts may not 

reach local organizations serving 

communities in need. 

Communities in greatest need may 

not have sufficient resources to 

address issues of violence. 

OPPORTUNITIES TO MAXIMIZE IMPACT 

• Provide support and build capacity for 

local groups to be involved in violence 

prevention efforts. 

• Train residents in identifying risk and protective 

factors for violence, and implementing strategies 

to prevent violence. 

• Find ways to engage youth and survivors of 

violence who offer a unique perspective. 

• Integrate violence prevention efforts into 

other strategies addressing chronic illness, 

economic and community development, and 

educational attainment. 

• Explore creative solutions for leveraging related 

initiatives and resources. 

Build the Team: Partnership for Success 

Successful efforts to implement community violence prevention strategies depend on bringing a diverse set 

of partners to the table early, consistently, and authentically. These partners may include the following: 

• Community-based organizations • Media 

• Community members, including former gang • Police, criminal, and juvenile justice agencies 

members, survivors of violence, and youth • Public health agencies 

• Faith-based organizations • School districts, universities, and 

• Family members, including caregivers community colleges 

• Health care systems, hospitals, community • Social service agencies 

clinics, and health care providers • Youth development organizations 

• Local businesses 

HEALTH EQUITY IN ACTION 

Building Community Capacity to Foster Healthy and Safe Communities 

Louisville, KY and community blight. When the Louisville Center 

for Health Equity, the Shawnee Neighborhood Residents of the Shawnee neighborhood of Louisville Association, and local youth joined together to experience more negative health outcomes and reduce violence, they promoted a sense of safety higher rates of violence compared to some other by working with local businesses to decrease the local communities.230 Many of the neighborhood’s presence of alcohol promotions, increase street violent assaults have been linked to poor community lighting, and eliminate graffiti and blight. These conditions, including an overabundance of alcohol improvements, which were supported by the 

cdc.gov/healthequityguide 97
Convergence Partnership, were aimed at creating 

an environment where residents could walk around 

safely, increasing access to their local grocery store 

and recreational spaces. 

The project cultivated leadership by working with 

youth as well as adult residents, encouraging them 

to become active in their own community. Shawnee 

youth engaged in conversations confronting equity 

issues—exploring how oppression and institutional 

racism make communities unsafe and unhealthy. 

The youth took this analysis to heart, shifting 

their focus from individual issues toward broader 

community solutions. 

HEALTH EQUITY IN ACTION
�

Using Crime Prevention Through Environmental 

Design and digital storytelling, youth and adults 

identified environmental determinants that 

influenced safety and physical activity. Poignant 

photos and videos captured neighborhood assets 

and concerns and informed recommendations to 

decision makers. Over 18 months, the Shawnee 

neighborhood saw many improvements: 

neighborhood blight decreased, retailers removed 

tobacco and alcohol advertisements from storefronts, 

and the city facilitated major street repair. 

Building a Culture of Peace through Resident Engagement 

Boston, MA 

Some communities in Boston experience 

disproportionate rates of violence.227 Such violence 

may create concerns for businesses, such as 

grocery stores, to locate in these communities and 

for residents who may want to walk and be active 

in their neighborhood.228,229 To address this issue, 

the Boston Public Health Commission (BPHC) 

uses a public health approach to prevent violence 

in these communities with support from a variety 

of federal and local funds. BPHC focuses on 

engaging community members, building autonomy 

in neighborhoods, and fostering connectedness 

between residents. 

In November 2007, the mayor, health commissioner, 

and police commissioner decided to make violence 

prevention a Boston priority. This commitment 

was key to ensuring that resources and support 

were allocated to the issue. With the help of more 

than 100 city staff across all agencies plus a large 

number of volunteers, BPHC led a neighborhood 

assessment and educational initiative, visiting every 

single house in neighborhoods heavily impacted 

by violence. BPHC provided more than 1,100 

backpacks filled with information about BPHC and 

preventing violence. Residents also completed 

more than 700 surveys. The results identified 

community policing, communities working together, 

and youth programs as possible ways to prevent 

violence in their neighborhoods. 

Using results from the assessment, BPHC 

developed the Violence Intervention and Prevention 

Initiative (VIP), which supports community-based 

organizations bringing together neighborhood 

coalitions including youth, long-time residents, 

and local businesses. Through community 

education, VIP coalitions work to ensure residents 

have the knowledge and resources to drive 

sustained improvements that decrease violence 

where they live. Each local coalition developed 

neighborhood violence prevention plans tailored to 

the community’s needs and priorities. Dr. Barbara 

Ferrer, BPHC Executive Director noted, “Resident 

engagement was so important for us [because 

preventing violence is] about a culture of 

building peace.” 

BPHC provides funding and technical assistance 

for a community organizer and block captains in 

each neighborhood. BPHC also supports a 

network of coalitions across all the neighborhoods. 

The network enables residents to share lessons 

learned and continue to build their capacity to 

address violence. 

cdc.gov/healthequityguide 98
APPENDICES 

APPENDIX A 

Health Disparities in Chronic Disease Risk Factors by Population Group 

APPENDIX B 

Considerations for Health Equity-Oriented Strategy Selection, Design, and Implementation 

APPENDIX C 

Example Resources for Identifying and Understanding Health Inequities 

APPENDIX D 

Health Equity Checklist: Considering Health Equity in the Strategy Development Process 

cdc.gov/healthequityguide 99
 

Despite decades of effort to reduce and eliminate health disparities, they have largely persisted—and in some 

cases are widening.9-11 Specifically related to chronic diseases, there is a concentrated, disproportionate 

burden of chronic disease in many underserved populations and communities. The table below describes 

disparities in chronic disease risk factors by various population groups. 

HEALTH DISPARITIES IN CHRONIC DISEASE RISK FACTORS BY POPULATION GROUP 

PEOPLE OF COLOR 

(RACIAL/ETHNIC 

MINORITIES) 

PEOPLE WITH 

MENTAL OR 

SUBSTANCE USE 

DISORDERS 

PEOPLE LIVING 

IN RURAL 

COMMUNITIES 

PEOPLE WITH 

DISABILITIES 

According to the 2010 Census, approximately 16% of Americans identified 

themselves as Hispanic or Latino, 13% as Black, 5% as Asian, 1% as American 

Indian and Alaska Native, and 0.2% as Native Hawaiian and other Pacific 

Islander.231 On a variety of health indicators, significant disparities among 

these racial and ethnic minorities continue to exist.7,232 For example, adult 

obesity rates in the U.S. are higher among non-Hispanic African Americans 

(50%) and Mexican Americans (40%) than among non-Hispanic Whites 

(35%), and they are highest among African American women, at 59%.233

In 2011, cigarette smoking among adults was highest among American Indian/ 

Alaska Native populations (32%), compared to other racial/ethnic groups.234 

In the United States, adults with mental or substance use disorders comprise 

approximately 25% of the population. However, this population accounts for 

an estimated 40% of all cigarettes smoked resulting in a disproportionate 

burden from the health consequences of smoking.235 

Approximately 19%, or 60 million Americans, live in rural areas.236 Rural 

residents are more likely to be elderly, in poverty, in fair or poor health, and 

to have chronic health conditions.48 For example, the prevalence of obesity 

is higher in rural adults (40%) than urban adults (33%).237 Adults living in 

non-metropolitan counties also have a higher average annual percentage of 

smoking (27%) than adults living in large metropolitan counties (18%).238 

Approximately 20% of U.S. adults have a disability.239 Approximately 28% of 

adults with disabilities smoke, compared to 16% of those without a disability.31 

Adults with disabilities are more likely to be physically inactive (22%) than are 

adults without disabilities (10%).240 Obesity is also higher among adults with 

a disability (38%) compared to those without a disability (24%), according to 

self-reported data.241 

APPENDIX A 

cdc.gov/healthequityguide 100
 

PEOPLE WITH 

LOW-INCOME 

AND THOSE 

EXPERIENCING 

POVERTY 

PEOPLE WITH 

LESS THAN A 

HIGH SCHOOL 

EDUCATION 

OLDER ADULTS 

PEOPLE WHO 

IDENTIFY AS 

LESBIAN, GAY, 

BISEXUAL, OR 

TRANSGENDER 

(LGBT) 

In 2011, an estimated 15% of the U.S. population lived below the federal 

poverty level.152 Poverty is correlated with perceived and actual poor health 

outcomes. People living in poverty are five times more likely to report 

their health as “poor” compared to high-income individuals.242 People with 

a household income below the poverty line (29%) have a much higher 

prevalence of smoking compared to people with household incomes at 

or above the poverty line (18%).234 Healthy eating (specifically fruit and 

vegetable consumption) is also lower among low-income populations 

compared to higher income populations.243 

Approximately 15 % of Americans 25 years old and older have not earned a 

high school diploma.244 Those with undergraduate degrees have a lower 

prevalence of smoking (9%), compared to those with less than a high school 

education (25%) or only a high school diploma (24%).234 Additionally, those with 

a GED have the highest prevalence of smoking (45%). Regarding obesity, college 

graduates or above had the lowest rate of obesity (28%) in 2009-2010, compared 

to those with less than a high school education (38%).245 

The proportion of our nation’s population aged 65 years and older is 

expected to increase from approximately 13% of the population in 2010 to 

an estimated 19% in 2030.246 In 2009–2010, 45% of adults aged 65 and over 

were diagnosed with two or more chronic conditions.247 Regarding inequities, 

older adults living in poverty and isolation may be particularly vulnerable.248 

The lesbian, gay, or bisexual population is estimated at 3.5% in the United 

States, with an additional 0.3% identifying as transgender.249 Regarding 

sexual orientation, use of any tobacco products have been found to be higher 

among lesbian, gay, bisexual, and transgender populations (38.5%) compared 

to the heterosexual/straight population (25.3%).61 Obesity prevalence has also 

been noted among the LGBT community, particularly among lesbians who 

have been shown to have a higher prevalence of being overweight and obese 

than heterosexual women who are overweight and obese.250 

NOTE: This list is not exhaustive and the groups are not mutually exclusive; individuals may belong to 

more than one population group. 

cdc.gov/healthequityguide 101
 

 

 

 

 

 

 

 

1 

Policy, systems, and environmental improvement strategies have great potential to prevent and reduce 

health inequities, affect a large portion of a population, and can also be leveraged to address the underlying 

social determinants of health. However, without careful design and implementation, such interventions 

may inadvertently widen health inequities. Collaborate with partners and community members, including 

those experiencing health inequities, to identify possible barriers or negative unintended consequences 

that may limit a strategy’s effectiveness. Then, account for identified challenges in strategy development to 

maximize the health effects for all and reduce health inequities. Consider the following barriers, unintended 

consequences, and questions when selecting, designing, and implementing equity-oriented strategies: 

APPENDIX B 

CONSIDERATIONS FOR HEALTH EQUITY-ORIENTED STRATEGY SELECTION, 

DESIGN, AND IMPLEMENTATION 

LIMITED 

COMMUNITY 

CAPACITY AND 

RESOURCES 

VARIABILITY 

IN HEALTH 

LITERACY 

LACK OF COMMUNITY 

ENGAGEMENT, 

AWARENESS, AND 

PARTICIPATION 

Variability in community capacity and 

resources can influence decisions about 

which communities and community 

organizations to partner with, especially 

if resources are limited. While there are 

benefits to funding and collaborating 

with partners that can “hit the ground 

running,” it is also important to build 

the capacity of other groups through 

training and additional support. 

Addressing health literacy means 

ensuring that all members of the 

community have the capacity to access 

and understand the information they 

need to engage in health improvement 

strategies or reap their health benefits. 

A well-designed effort may fail to reach 

its full potential if residents are unaware 

of the improvements or were not invited 

to participate in the planning and 

implementation process. Community 

residents and stakeholders should be 

consulted and engaged from the very 

start, and this engagement should be 

sustained throughout the process. 

• Has lack of capacity or resources kept 

critical partners away? 

• What training opportunities can build the 

capacity of residents or organizations to 

make community improvements? 

• Are the same organizations repeatedly 

benefiting from funds distributed in the 

community? What steps can you take to 

engage other organizations? 

• Will the improvements be understood by 

all community members? 

• Is training needed to support and sustain 

the improvements? 

• How will language, culture, and other 

differences be accommodated? 

• How will stakeholders representative of 

the community’s diversity be engaged? 

• What steps will be taken to engage 

community members in planning, 

implementation, and evaluation? 

2 

3

cdc.gov/healthequityguide 102
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4 

COST, RESOURCES, 

AND OTHER FISCAL 

CONSIDERATIONS 

5 

TRANSPORTATION 

CHALLENGES 

POTENTIAL 

DISPLACEMENT 

EFFECTS 

VARIABILITY IN 

IMPLEMENTATION 

CRIME/SAFETY 

INFLUENCES (BOTH 

REAL AND PERCEIVED) 

6 

7 

8 

There may be costs related to strategy 

implementation, either for the institutions 

making the improvements, or for the 

people who are the intended 

beneficiaries of these improvements. 

Examine how budget constraints may 

hinder implementation or uptake in 

underserved communities. 

Lack of personal transportation, 

unaffordable or unreliable public 

transportation, or inadequate infrastructure 

may reduce access to goods, services, 

or environmental improvements, 

including tobacco cessation services 

and other health care services. Explore 

whether transportation issues such as 

access, cost, and proximity exist. 

Changing community conditions may 

contribute to cycles of displacement. It is 

important to ensure that improvements 

will benefit residents rather than create 

conditions that displace them. Identify 

factors that may drive displacement and 

protections that can prevent it. 

Uneven implementation of a policy or 

systems improvement may worsen 

inequities. Explore the factors (including 

those listed in this table) that might 

prevent consistent implementation of a 

strategy and develop solutions early in 

the planning process. 

Even if effective strategies are put in place, fear 

of crime at locations where the intervention or 

service is being delivered may keep residents 

from using the new resources. Assess safety 

conditions and residents’ perceptions of these 

conditions, and, if necessary, take steps to 

ensure participants’ safety. 

• Will costs prevent underserved populations 

from fully benefitting from the strategy? 

How can affordability be ensured for all? 

• Which partners might be able to help 

provide required resources (e.g., funding, 

materials, staff, other assets) to implement 

the strategy? 

• Is lack of transportation a problem for the 

intended beneficiaries of the strategy? 

• Are the locations where services are 

provided too distant, inconvenient, 

inaccessible, or unsafe? 

• How might community improvement 

strategies lead to displacement in the future? 

• What protections can be put in place 

to preserve affordable housing and 

prevent displacement? 

• How might concerns about displacement 

prevent residents from engaging in 

community improvements? 

• Once your strategy is adopted or 

implemented, what steps will ensure 

proper implementation? 

• How will you ensure implementation 

occurs where it’s needed most? 

• Which institutions need additional support 

to implement the improvements? 

• How might concerns about safety prevent 

the community from benefitting from 

the strategy? 

• Are there visible signs of crime 

and violence? 

9 

LACK OF 

AWARENESS OF 

DIVERSE NORMS 

AND CUSTOMS 

Understanding the diversity in culture, 

norms, and customs among population 

groups can ensure that strategies are 

designed to be inclusive. Institutions also 

have their own customs and norms, and 

these should also be considered, as they 

might affect decision making. 

• How will community members with 

different norms and customs be engaged 

in strategy design? 

• Are differences in culture and norms 

understood in ways that result in respectful 

strategy development? 

cdc.gov/healthequityguide 103
BEHAVIORAL 

RISK FACTOR 

SURVEILLANCE 

SYSTEM (BRFSS)251 

CENSUS DATA252 

COMMUNITY 

COMMONS253

COMMUNITY HEALTH 

ASSESSMENT & GROUP 

EVALUATION (CHANGE): 

BUILDING A FOUNDATION 

OF KNOWLEDGE TO 

PRIORITIZE COMMUNITY 

NEEDS17 

COUNTY HEALTH 

RANKINGS: 

MOBILIZING 

ACTION TOWARD 

COMMUNITY 

HEALTH254 

A state-based system of health surveys that collects information on health 

risk behaviors, preventive health practices, and health care access primarily 

related to chronic disease and injury. 

A database that provides demographic information on income, education, 

race/ethnicity, housing, and other factors that are viewable at multiple 

levels: national, state, county, and smaller geographic areas. Interactive 

features also allow cross tabulation of indicators and population groups. 

An online interactive mapping tool that provides free geographic 

information systems (GIS) data from the state level to the block group level. 

The Commons is linked to the National Prevention Strategy and provides a 

peer learning network and other resources. 

A tool to help community teams develop a community action plan. 

This tool provides steps for community team members to use in an 

assessment process. It also helps define and prioritize possible areas of 

improvement to address the root causes of chronic diseases, as well as 

related risk factors. 

A ranking of counties in each of the 50 states according to summaries of a 

variety of health measures. Summary measures include health outcomes 

(mortality and morbidity) and health factors (health behaviors, clinical care, 

social and economic aspects, and physical environment). 

This table describes several online resources that you may be able to use to identify and understand health 

inequities in your area. This list is not exhaustive and you should determine what best fits your local needs. 

APPENDIX C 

EXAMPLE RESOURCES FOR IDENTIFYING AND UNDERSTANDING HEALTH INEQUITIES 

cdc.gov/healthequityguide 104
COMMUNITY 

HEALTH STATUS 

INDICATORS 

(CHSI)255 

DATA SET 

DIRECTORY 

OF SOCIAL 

DETERMINANTS 

OF HEALTH AT THE 

LOCAL LEVEL256 

HEALTHY 

COMMUNITIES 

NETWORK (HCN)257 

HEALTH 

DISPARITIES 

CALCULATOR258

HEALTH EQUITY 

INDEX259

HEALTH 

INDICATORS 

WAREHOUSE260

THE TOOL FOR 

HEALTH AND 

RESILIENCE IN 

VULNERABLE 

ENVIRONMENTS 

(THRIVE)261 

A report that contains over 200 measures for each of the 3,141 U.S. 

counties. The report presents indicators for deaths due to heart disease 

and cancer as well as on behavioral factors such as tobacco use, diet, 

physical activity, alcohol and drug use, sexual behavior, and others that 

substantially contribute to these deaths. 

A directory that contains an extensive list of existing data sets that can be 

used to address social determinants of health. The data sets are organized 

according to 12 dimensions (broad categories) of the social environment. 

A network that tracks over 200 health and quality-of-life indicators. 

It also provides guidance on 1,800-plus community-level interventions. 

Local information is collected and combined with other data. 

Statistical software from the National Cancer Institute that 

imports population-based health data and calculates different 

disparity measurements. 

An online tool created by the Connecticut Association of Directors of 

Health that outlines and measures the social determinants of health with 

specific health outcomes. The index produces scores as well as GIS maps.

A Web site maintained by CDC’s National Center for Health Statistics. 

This resource provides data on communities’ health status as well as 

different determinants. There are over 1,000 indicators that can be 

categorized by geography, initiative, or topic. 

A tool intended to help people understand and prioritize the factors 

within their own communities in order to improve health and safety. 

The tool identifies key factors around equitable opportunity, people, and 

place, and allows users to rate how important each factor might be in 

their community. 

cdc.gov/healthequityguide 105
 

 

 

 

 

 

 

 

 

 

 

 

 

 

The Health Equity Checklist provides questions for consideration when designing a strategy to ensure health equity 

remains central to all aspects of an initiative. 

Clearly identify health inequities and protective factors in both health outcomes and community conditions across population 

groups and geographic areas through the use of existing data, community input, and environmental assessments. 

Review evaluation and monitoring plans to ensure health equity-related efforts will be measured. Additionally, ensure 

appropriate data will be collected to conduct sub-analyses. These data will help in assessing the differential effects of 

each strategy across population group(s)/area(s), as well as the overall impact of strategies on reducing health inequities. 

Include and meaningfully engage representatives of population(s)/area(s) defined in Step 1 in your partnerships, 

coalitions, or on leadership teams. 

APPENDIX D 

STEP 1: IDENTIFY 

STEP 2: ENGAGE 

STEP 3: ANALYZE 

STEP 4: REVIEW 

SUGGESTED CITATION: Centers for Disease Control and Prevention - Division of Community Health. Health Equity Checklist: Considering 

Health Equity in the Strategy Development Process. Atlanta, GA: US Dept of Health and Human Services; 2010. 

Ensure the selection, design, and implementation of strategies are linked to the inequities identified in Step 1, and will 

work to advance health equity. Consider the following: 

Is the strategy TARGETED to a population group(s)/area(s) experiencing health inequities? 

• Is the outcome written in a way that allows you to measure the effect of efforts? 

• Is it culturally tailored to the unique needs of population group(s)/area(s) experiencing health inequities, and are 

potential barriers addressed? 

Does the strategy rely on SITE SELECTION (e.g., selecting X number of sites for smoke-free cessation services, 

creating X number of farmers’ markets)? 

• Do selection criteria for sites reflect populations/areas with the highest burden? 

• If not, are selection criteria logical and justified? 

• Are there additional supports provided for selected sites that might require them to be successful? 

Is the strategy POPULATION-WIDE? 

• Have population(s)/area(s) experiencing health inequities been engaged in efforts to identify 

possible barriers and unintended consequences of the proposed strategy? 

• Are identified barriers regarding implementation and enforcement being addressed? 

• Have potential unintended consequences been considered and accounted for in proposed activities? 

HEALTH EQUITY CHECKLIST: CONSIDERING HEALTH EQUITY IN THE STRATEGY 

DEVELOPMENT PROCESS 

106
 

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