The function of the public health system relies heavily on the work of training developers and educators as they prepare the workforce to respond to and address emerging concerns and priorities.¹ Training developers and educators help share necessary knowledge and build strategic skills among the public health workforce, including persons new to the field and those without formal training in public health. Training developers and educators have a crucial role in training multidisciplinary public health practitioners in key public health concepts to advance priorities of the field.²

Reflecting the shifting culture and context in the United States, one such priority issued through Executive Order 14035 is to “strengthen the governmental workforce by promoting diversity, equity, inclusion, and accessibility” (DEIA).³ The Centers for Disease Control and Prevention (CDC) responded by developing CDC’s CORE (cultivating comprehensive health equity science, Optimizing interventions, Reinforcing and expanding robust partnerships, Enhancing capacity and workplace diversity, inclusion, and engagement) Health Equity Science Intervention Strategy.⁴ In 2020, CDC’s Division of Workforce Development (DWD) set core milestones for training within fellowships housed in the division, which include public health practitioners such as informaticians, epidemiologists, laboratorians, and evaluators.⁵ DWD recognizes current competencies and skill-building priorities, including that (1) knowledge and skills in health equity (including DEIA) are necessary to functionally collaborate across specialties within the workforce and advance public health efforts addressing social determinants of health,⁶ and (2) Core Competencies for Public Health Practitioners infuses health equity and DEIA throughout all domains, but specifically addresses the topic in Domain 4: Health Equity Skills.⁷ DWD prioritizes providing fellows and future public health leaders with health equity training to help ensure “everyone has a fair and just opportunity to attain their highest level of health.”⁸ The division’s fellowship educators prioritize using evidence-based teaching methods to strengthen competency-based fellowship curricula. The literature review was needed to find evidence-based recommendations to teach DEIA and a health equity lens for the scientific public health work that CDC trains fellows to conduct. Using the evidence to strengthen curricula was especially important as racism was declared a public health threat,⁹ and a large body of health education evidence had not been identified. We conducted this literature review to address this gap.

The purpose of this semisystematic literature review was to identify current evidence-based methods that training developers and educators can apply when teaching DEIA and health equity principles to public health practitioners from various disciplines in the workforce. Multiple teaching methods can be used to help learners build knowledge and skills. Because training developers and educators may work with limited resources, strategically choosing methods to apply in educational programs is paramount to efficiently yielding effective results. The findings of this literature review are relevant to professionals working toward similar goals of systematically advancing health equity and DEIA efforts in various public health workforce education models and settings.

We conducted a semisystematic literature review because this methodology’s purpose is to extract rich, in-depth descriptions that match our aim to search for common teaching methods to apply.¹⁰ Semisystematic reviews aim to assess the current state of knowledge.¹⁰ These reviews research broad questions, use qualitative text from research articles, and thus use inductive qualitative analysis. Semisystematic reviews are useful “when wanting to study a broader topic that has been conceptualized differently and studied within diverse disciplines.”¹⁰ In contrast, systematic reviews have more narrow research questions, focus on quantitative outcomes data, and use quantitative or mixed methods, while integrative reviews take a critical lens to analyze information and create new theoretical frameworks.¹⁰ A semisystematic approach was the best fit for our purposes because it yielded a rich overview of teaching method descriptions.

Our literature review revealed different evidence-based methods for teaching DEIA concepts, 6 of which emerged as primary themes (Table 1). Several articles applied a multimodal approach that combined multiple teaching methods to achieve results, and we grouped those articles by the primary method used. Authors reported different settings in which DEIA and health equity programs were implemented, including but not limited to university classes, the workplace, and clinical education and training. All articles included considered a match of methods to the needs of the audience, context, and other factors that best fit the content while teaching, using methods inclusive of different learning styles (Table 2).

“Critical reflection” creates opportunities for self-reflection that helps learners understand a given public health problem. Learners reflect on personal, lived experiences and use that reflection to advance their learning. The literature emphasizes that instructors and learners need to engage in introspective thought processes for this method to be successful in fostering learning.¹⁴ Reflection is more than assigning a reading and requiring that learners reflect in a written journal or discussion post. de la Croix and Veen note that this can appear that the learner is reflecting but might be going through the motions without internalizing any change.¹⁵ To support true reflection, the authors encourage embracing diversity, making reflection an iterative process, and diving into the less structured aspects of life and work as opportunities for growth.¹⁵ Aqil et al examined ways that faculty at schools of public health across the United States incorporated reflection into their teaching in the framework of anti-oppression and social justice.¹⁴ Their study reported that critical reflection, creating equitable classrooms, and discussing historical contexts of systems of oppression were key in anti-oppressive teaching.

“Service learning” or critical service learning (CSL) establishes projects for participants to serve their community. “CSL draws together theory and research with a community-led project that aims for social change, authentic relationships, and the redistribution of power”.¹⁶ Learners engage with material by practicing skills learned in the classroom in a real-world environment and gain hands-on experience as public health professionals. The literature suggests that this method can be a positive way for a program or workplace to give back directly to the community that they serve.^17,18 Biswas and Izard found that CSL helps students engage in topics of diversity and inclusion.¹⁷ They reported this method to be particularly helpful in infusing DEIA into courses that did not have a specific DEIA focus. Costley, Nottingham, and Nikolou-Walker similarly reported that CSL is a tool for teaching DEIA and identified it to be a useful teaching method for learners with less traditional academic backgrounds.¹⁸ In exploring the application of CSL in a public health nursing and a public health evaluation course, Derreth, Jones, and Leven noted that this method can be time-consuming and resource-intensive.¹⁶ Therefore, the benefits generated need to be evaluated against organizational capacity to support their learners. A significant benefit of service learning is that learners can directly serve their community using skills they are developing in the classroom.

“Case studies, or case-based learning,” allow learners to apply public health concepts to realistic scenarios they might experience as working professionals. Instructors can develop scenarios based on their professional experience and educational materials or adapt real-life cases for their students to review. In one article, Hoffer tied case-based learning to the historical practice of storytelling as a framework for expanding the learners’ worldview.¹⁹ In another article, senior pediatrics residents at Boston Medical School solicited examples of cases from physicians where bias played a role in patient outcomes. The learners talked through the cases to discuss what role they would play in preventing bias and structural racism from negatively affecting their patients. The conversations about the cases originally occurred in larger groups but were changed to small group discussions based on student feedback, making the learning process iterative and engaging. After the third session, 100% of participants agreed they were able to identify tools, resources, and opportunities to combat implicit bias.²⁰

“Peer-learning and dialogue” creates opportunities for learners to discuss health equity and DEIA concepts in connection with personal lived experiences and engage in discourse with other learners. This method can be a natural continuation of critical self-reflection, but where self-reflection can be primarily internal, peer learning and dialogue places learning on the connections that we make with others. In the literature, peer learning was largely facilitated in classroom settings. Learners were often presented with a topic or question for discussion. They might have been given time to reflect in a written discussion post or on their own for internal silent reflection and then share their thoughts with others. Vesperman’s “Transforming the Activity of Teaching a Foundation of Diversity and Equity Course” noted that instructors relied immensely on this method during the COVID-19 pandemic when a shift to virtual learning occurred.²¹ Another article described how peer learning and dialogue can be especially valuable when the student population is diverse itself. In this study, professors focused on a specific “interim point.” This is when the professor converts subject matter that differs from students’ everyday knowledge into personal or practical ideas familiar to students and asks students to discuss with others. Using a public health example, an instructor might lead discussion about immunizations and vaccines by asking learners to share their personal experiences and then discuss the public health implications of vaccinations. Learners can share their lived experiences, learn from the experiences of others, and tie them to broader topics in health equity and DEIA. One instructor shared that they taught a diverse student body and found that this method provided multiple opportunities for students to learn how other people view things from a perspective different from their own.²²

“Workshops” are short-term trainings often focused on specific topics. Workshops can differ in length, ranging from a few hours to days. One study used a 2-day workshop for teaching DEIA to first-year medical students. The “Differences Matter Orientation” workshop focused on 3 pillars of learning, including personal narratives, relationship-centered communication, and upstander training. The article notes that this method was especially effective in building relationships between students and faculty by using a curriculum that includes, rather than ignores, race and other social determinants.²³ Additionally, tailoring a workshop to the specific needs of a learner population is important.²⁴ In the article “Critical Consciousness as a Framework for Health Equity,” instructors used a critical consciousness framework to produce a 5-day workshop for first-year medical students. The workshop focused on introducing problems of discrimination and inequity that affect patient health outcomes. At the workshop conclusion, students completed a self-assessment evaluation tool used by other authors in this literature review. A workshop requires different follow-up support to ensure concepts are being absorbed beyond the training, and can be a great starting point for continued learning.^25,35

“Simulation learning” casts learners into a role and allows them to act out a given scenario as it might occur in the field. Simulation can take the form of a computer program or immersive technology. On the low-tech side, simulation can look like role-play, where learners are given a prompt or loose script and act it out with others. The use of simulation technology has become increasingly popular in more recent years.²⁶ In one article, students were tasked with writing a reflection on an assigned reading before being divided into groups to exercise a realistic diversity challenge. That challenge was to create a list of diversity concerns for the Dean of Students at their university.²⁷ As a method, simulation can be valuable in that learners can practice applying concepts of health equity and DEIA in realistic scenarios, while remaining within the bounds of a learning environment.

Our literature review yielded 6 evidence-based methods for teaching health equity and DEIA that can be applied to different workforce training and development programs and align with best practices for training and education efforts. Several considerations for best practices emerged from this research. First, using multiple methods is a strategy to support different learning styles among diverse audiences. Second, content and teaching methods should be tailored to the specific audience and learning environment based on training needs analysis recommendations. By gathering information about the learners, identifying opportunities to build trust and engage, and determining potential barriers and facilitators for training, the training needs analysis can help training developers and educators ensure inclusion and accessibility and advance equity through the training.²⁸ Third, audience members might relate more to training developers and educators of the same or similar backgrounds than to an educator from another group. A common practice in public health is to involve members of the primary population in intervention efforts. Those who develop educational programs might consider weighing the benefits of applying that strategy for engagement with the potential detrimental effects of placing onus on persons who might be adversely experiencing inequity themselves.²⁹ Finally, our literature search revealed a gap in evaluation data collection of health equity and DEIA teaching methods, particularly the evaluation of higher levels of the Kirkpatrick Four Levels of Training Evaluation. This finding is not unexpected because collecting evaluation data can be difficult, especially outcome evaluation data after learners have had time to apply what they have learned. Future evaluation of educational programs might consider assessing and sharing longer-term effects at higher levels, including behavior change (K3) and long-lasting results (K4).

Several limitations of this literature review were encountered. The methods identified represent just a few ways that authors have taught health equity and DEIA. Other methods like Universal Design for Learning have been used and may be effective, but without strong evidence of use in the literature, we did not identify them as primary themes. Findings might not be inclusive of trainings related to social determinants of health, which might have been found using topic-specific search terms like K-12 education, housing, preventative care, or transportation. Although training developers and educators are engaged in health equity and DEIA training initiatives to address disparities, educational programs on these concerns remain largely unstudied or unpublished.

We conducted this literature review to support efforts to infuse health equity and DEIA training within DWD’s fellowship education programs in addition to supporting the work of the larger training developer and educator workforce. Fellowships within DWD have a host site design with training curricula built to support and enhance learning.⁵ We have been working to infuse health equity and DEIA principles throughout curricula for different public health topics. After completing this research, we began conducting reviews of all DWD fellowship program curricula to incorporate the 6 methods and training considerations found in this literature review. Ensuring evidence-based methods are applied across all topics was part of a larger effort to embed health equity and DEIA principles into existing structures and processes. We also shared the findings from this research in an internal Health Equity Roundtable, and as a result, prioritized (1) continuing interdisciplinary trainings, (2) embedding health equity principles into guidelines and structures for fellowship curriculum plans, and (3) developing interdisciplinary case studies where multiple fellowships can collaborate on case study and simulation activities. To help address the gap in evaluation data on these methods, we have also developed standardized questions to collect qualitative and quantitative data on the outcomes of our trainings.

Training developers and educators are equipped with different teaching methods to enhance the skills of public health practitioners from multiple disciplines. They can use the method or blend of methods that they determine are culturally appropriate, relevant, and best meet learner needs based on the needs assessment and training needs analysis for the audience and setting. As the national discourse continues to evolve, training developers and educators can continue to play a pivotal role in training public health practitioners by centering health equity and DEIA principles to improve public health.