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ETR's Health Equity Framework: A Mission-Focused Tool

ETR's Health Equity Framework: A Mission-Focused Tool

By Vignetta Charles, PhD & Karin Coyle, PhD | April 24, 2018
CEO (VC) & Chief Science Officer (KC), ETR

At ETR, we advance health equity through science-based solutions. We’ve been doing it for 37 years. But it wasn’t until recently that we developed our own framework to explicitly and transparently ground our work in health equity. This more intentional approach to health equity has energized our mission-driven work.

We’re excited about this framework because it does more than enhance the vision of our organization. It also offers a kind of scaffolding that we believe may be useful to other organizations working in equity-based research, health promotion and human services.

Creating a Framework

How did we do it? First, our transdisciplinary team scoured the literature. We looked for models that fit our intersectional approach. We wanted a framework that reflected the decades of learning and experience ETR has in behavior change strategies. We wanted something that was responsive to our particular areas of focus: sexual health, HIV, legal and illegal drugs, school-based health and wellness, and equity and inclusion in STEM.

That was a tall order and, truth be told, we couldn’t find a model that fit. So we created our own! May we introduce you to ETR’s Health Equity Framework.

We are building on—and now contributing to—the evidence base for advancing health equity. As part of our creation process, we reached out to stakeholders and our Board for input around language and visual representation. For example, take a look at this post by Board member and thought leader Cynthia A. Gómez.

These efforts reflect our desire to create a framework that is both (1) broadly accessible, and (2) able to visually explain the ways health outcomes are influenced by complex interactions between people and their environment.

ETR’s Health Equity Framework (HEF)

  • The Health Equity Framework is a model that explains the ways health and education outcomes are influenced by complex interactions between people and their environment.
  • Health equity means having the personal agency and fair access to resources and opportunities needed to achieve the best possible physical, emotional and social well-being. Health inequities are the preventable differences in health outcomes that are closely linked to social, economic and environmental conditions. 

Many programs and strategies seeking to shape health and education outcomes focus solely on an individual’s knowledge, attitudes, skills and behaviors. Simplistic messages such as “always use a condom” or “stop smoking” have been the foundation of many behavioral interventions. These interventions miss the opportunity to take into account the multiple spheres of influence that impact health and education outcomes.

For instance, where in such slogans do we find biology and development? How about relationships and networks? What about the influence of systems of power? Along with individual factors such as knowledge or attitude, these other factors play a powerful role in either promoting health equity or intensifying inequities.

The Heart of the HEF: Four Interconnected Factors

There are four interconnected factors that influence and determine health equity and health inequities.

Systems of Power. Policies, processes and practices that either:

  • Promote health equity through fair access to resources and opportunities that enable healthy lives; OR
  • Intensify health inequities by allowing unfair social, economic or environmental advantages for some groups over others.

Relationships and Networks. Connections with family, friends, partners, community, school and workplaces that either:

  • Promote health equity through support systems that encourage health-promoting choices; OR
  • Intensify health inequities through social networks that enable health-harming behaviors.

Individual Factors. A person’s responses to social, economic and environmental conditions that either:

  • Promote health equity through attitudes, skills and behaviors that enable their personal and community’s health; OR
  • Intensify health inequities through attitudes, skills or behaviors that cause harm to their personal or community’s health.

Biological Pathways. Physiological factors that either:

  • Promote health equity when a person’s physical, cognitive and psychological abilities are maximized; OR
  • Intensify health inequities when a person’s environment or experience has impaired their physical, cognitive or psychological functions.

Interactions of these four factors occur across the lifespan. Some environmental conditions, relationships or behaviors have greater impact at different periods during the lifespan. Reflecting on these lifespan differences can help strengthen program efforts. 

We’re Getting More Specific

We apply the Health Equity Framework to our current work so we can be more specific in the ways we focus our approaches and measurement. We believe that addressing these factors collectively, as well as attending to their interconnectedness, is a critical element in influencing health and education outcomes. There are times, however (e.g., funder-driven mandates, project specifics) when we are only able to focus on one, two or three of these factors.

Bringing rigorous attention to the framework is enriching our project planning and broadening our approaches to promoting health and education outcomes. This, in turn, increases the potential for stronger and more lasting impact. You can see examples of the ways the Health Equity Framework applies to some of our current work at the HEF website (click on any of the projects listed below the page title to see how the HEF is being applied).

What’s Your Framework?

What frameworks do you apply to guide your work? Is this something that’s institutionalized in your setting? Would the Health Equity Framework be useful for you in its current form, or with some modification? How does the framework apply to your projects—which factors are being addressed?

This framework is empowering our work. We are eager to offer it as a way to boost efficacy in the field and build a stronger sense of community and vision among our colleagues and partners. Let us know how we’re doing. We’d love to hear from you.


Vignetta Charles, PhD, is CEO of ETR. She can be reached at Karin Coyle, PhD, is Chief Science Officer at ETR. She can be reached at

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