Centering Equity in Evidence-Informed Decision Making: Theoretical and Practical Considerations

Over the past 50 years, population health researchers have made significant progress in clarifying the empirical and theoretical relationships between socioeconomic conditions and health disparities^1-3 particularly for social constructs such as race and ethnicity.⁴ Health disparities, defined as “differences in health or its determinants that adversely affect marginalized or excluded groups,” are the metric to measure progress toward health equity,^5,6 meaning “assurance of the conditions for optimal health for all people.”⁷ At the same time, policymakers and public health practitioners have invested in and implemented interventions (i.e., policies and programs) that have empirical evidence supporting their effectiveness in a process called evidence-informed decision making (EIDM). EIDM refers broadly to a wide variety of approaches to find, assess, and implement relevant knowledge in decision making about social issues.^8, 9 EIDM originated from evidence-based medicine, a process popularized in the 1990s to improve clinical decision making by emphasizing systematic searches and evaluation of scientific literature and noting that “intuition, unsystematic clinical experience, and pathophysiologic rationale” were not sufficient for producing desirable outcomes.¹⁰ EIDM has been broadly adopted in many forms, including in population health, to improve decision making by practitioners and policymakers. Scientific or research evidence is often distinguished from tacit or colloquial evidence such as opinions, values, and habits and can be called “evidence based” or “evidence informed” to represent that research evidence is one of several factors influencing policymaking.⁹ EIDM—based on the process of searching, appraising, synthesizing, adapting, and implementing evidence into policies and practices¹¹—improves effectiveness and efficiency of interventions, facilitates an efficient use of limited resources, and improves transparency of decision making.⁹ As our knowledge has deepened about what shapes health and results in health disparities, the data and evidence we use to support EIDM have not evolved and now largely lack the precision and focus needed to address health equity. In 2021, the World Health Organization named equity as an explicit principle to consider in EIDM and thus urged monitoring observable differences in health to identify groups at risk⁹—meaning at risk for health inequity. The US Centers of Disease Control and Prevention (CDC) also launched its Cultivate, Optimize, Reinforce, and Enhance (CORE) Commitment to Health Equity framework in 2021, which marked the CDC’s first agencywide health equity strategy.¹² Recent research encourages broadening focus beyond health disparities to their structural causes and corresponding structural interventions,^4, 13 including scholar Camara Phyllis Jones, who notes, “Achieving health equity requires valuing all individuals and populations equally, recognizing and rectifying historical injustice, and providing resources according to need.”⁷

References

1. Green H, Fernandez R, MacPhail C. The social determinants of health and health outcomes among adults during the COVID-19 pandemic: a systematic review. Public Health Nurs. 2021;38(6):942-952. https://doi.org/10.1111/phn.12959.
2. Wang E, Glazer KB, Howell EA, Janevic TM. Social determinants of pregnancy – related mortality and morbidity in the United States. A systematic review. Obstet Gynecol. 2020;135(4):896-915. https://doi.org/10.1097/AOG.0000000000003762
3. NORC Walsh Center for Rural Health Analysis. Frameworks to address so-cial determinants of health. Rural Health Information Hub. March 6, 2020.Accessed October 16, 2024. https://www.ruralhealthinfo.org/toolkits/sdoh/1/framework
4. Lavizzo-Mourey RJ, Besser RE, Williams DR. Understanding and mitigat-ing health inequities — past, current, and future directions. N Engl J Med.2021;384(18):1681-1684. https://doi.org/10.1056/NEJMp2008628
5. Braveman P. A new definition of health equity to guide future efforts and mea-sure progress. Health Aff (Millwood). June 22, 2017. https://doi.org/10.1377/forefront.20170622.060710
6. Braveman P. What are health disparities and health equity? We need tobe clear. Public Health Rep. 2014;129(1_suppl2):5-8. https://doi.org/10.1177/00333549141291S203.
7. Jones CP. Systems of power, axes of inequity: parallels, intersections, braid-ing the strands. Med Care. 2014;52(Supplement 3):S71-S75. https://doi.org/10.1097/MLR.0000000000000216
8. Pan American Health Organization. A Guide for Evidence-Informed Decision-Making, Including in Health Emergencies. Pan American Health Organiza-tion; 2022. Accessed October 16, 2024. https://iris.paho.org/bitstream/handle/10665.2/55828/PAHOEIHKTCOVID1921038_eng.pdf?sequence=1&isAllowed=y.
9. World Health Organization. Evidence, Policy, Impact: WHO Guide for Evidence-Informed Decision-Making. World Health Organization; 2022. Accessed May 20,2024. https://www.who.int/publications/i/item/9789240039872.
10. Guyatt G, Cairns J, Churchill D, et al. Evidence-based medicine: a new ap-proach to teaching the practice of medicine. JAMA. 1992;268(17):2420-2425.https://doi.org/10.1001/jama.1992.03490170092032.
11. Evidence-informed decision making in public health. National CollaboratingCentre for Methods and Tools. Accessed May 20, 2024. https://www.nccmt.ca/tools/eiph