Last updated August 11, 2020

Health Equity Style Guide for the COVID-19 Response: Principles and Preferred Terms for Non-
Stigmatizing, Bias-Free Language
CDC’s Health Equity Style Guide emphasizes the importance of addressing all people inclusively, with respect, including using non-stigmatizing, bias-free
language. Avoid perpetuating negative stereotypes or blaming people for their own life circumstances or health status when reporting data or
information about health disparities. As you create information resources, give presentations, engage with partners, and even develop and review
internal communications, look for opportunities to apply the guidance below to your work in the response.

Using a health equity lens describes key considerations for framing information about health disparities and general public health implications.
Table 1 describes overarching principles to consider throughout public health response efforts, including written and oral dissemination of information.
Table 2 provides preferred terms for select population groups; the terms to avoid represent an ongoing shift toward non-stigmatizing language.
Table 3 provides considerations for developing community mitigation guidance and public health communications.
Table 4 provides links to references, other resources and style guides to avoid stigmatizing language used to develop this style guide.
Glossary includes definitions of key terms.

Using a health equity lens

Key health equity considerations to use when framing health disparities and discussing public health implications
When information is disseminated, several decisions are made regarding what to emphasize, how it is explained, and what is left unsaid. When
communicating about disparities, be sure to emphasize the value of ensuring that everyone has an equal opportunity for health and that reducing
disparities contributes to the common good and benefits all; explain that disparities can be prevented by equitable programs, policies, and services; and,
importantly, recommend solutions (or the need to develop innovative solutions). Also consider the following as you disseminate information.

• Long-standing systemic health and social inequities, including some that have been introduced by federal, state, and local policies, have put some
population groups at increased risk of getting sick from some illnesses, having overall poor health, and having worse outcomes when they do get
sick.
o Take every action possible to avoid implying that a person/community/population is responsible for increased risk of adverse outcomes.
o Health disparities should be contextualized by social determinants of health.
o State the situation or present the data objectively.
o Review the content while specifically looking for unintentional stereotyping, stigmatization, or blame brought about through word choices,
images, where the material is presented in relation to other content, or absence of contextualizing framing.
o Some members of disproportionately affected groups don’t have the resources to follow public health recommendations that are based on
‘ideal world’ scenarios. Resource allocation may not match need due to lack of an inclusive infrastructure.
o Meeting an immediate health-related need may not solve problems that are structural in nature (i.e., the factors that caused or could have
prevented the health-related need).

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• Health equity is intersectional – Individuals may belong to several groups that historically have experienced discrimination, and therefore, may have
layered health and social inequities. Such intersections must be further examined to better understand, interpret, and communicate health outcomes.
o Population groups are not homogeneous in their health and living circumstances.
o Race/ethnicity cannot serve as a proxy for socioeconomic status, and vice versa.
o There is diversity within and across communities, with variations in history, culture, norms, attitudes, behaviors, lived experience, and many
other factors. Be cautious in generalizing about a community (e.g., “the Hispanic community”).
o Use inclusive language to avoid unintentionally excluding certain groups (e.g., use gender-inclusive language if not referring to a specific sex or
gender group – e.g., chairperson instead of chairman, avoid using pronouns or use they or he/she).

• Public health programs, policies, and practices must recognize and respect the diversity of the community they are trying to reach.
o Community engagement efforts can help strengthen cross-sector partnerships, ensure culturally and linguistically appropriate practices, build
trust within communities, promote social connection, and advance health equity.
o Public health has an important role in addressing the social determinants of health in collaboration with multi-sector partners.
o Response efforts should tailor interventions and communication based on the unique circumstances of different populations.
o Consider a strengths-based framework for writing to ensure community strengths and solutions drive local public health response efforts while
also being sensitive to areas where a community’s capacity can be built.

Table 1. Overarching principles and preferred terms

Key principles Terms to avoid Preferred terms
Avoid use of the terms such as vulnerable, Vulnerable groups Disproportionately affected
marginalized, and high-risk as adjectives. Marginalized groups Groups that have been economically/socially marginalized
These terms can be stigmatizing. These terms are High-risk groups Groups that have been marginalized
vague and imply that the condition is inherent to At-risk groups Groups placed at higher risk/put at higher risk of [outcome]
the group rather than the actual causal factors. High-burden groups Groups at higher risk of [outcome]
Hard to reach groups Groups experiencing disadvantage
Targeted population Groups experiencing disproportionate impact
Population of focus
Under-resourced communities
Avoid dehumanizing language. Use person-first Examples:
language instead. Diabetics People with [disease]
Describe people as having a condition or Diabetes patients Patients with [disease] (if being treated)
circumstance, not being a condition. A case is an The diabetes population People experiencing [health outcome or life circumstance]
instance of disease, not a person. Use patient to COVID-19 cases People who are experiencing [condition]
refer to someone receiving treatment. The homeless Survivors
Inmates
Victims
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Key principles Terms to avoid Preferred terms
Remember that there are many types of Minorities Racial and ethnic groups
subpopulations. Minority Racial and ethnic minority groups
Ethnic groups Sexual/gender/linguistic/religious minority groups
Racial groups Political minority group (Note: American Indian and Alaska
Natives are the only federally recognized political minority in
the U.S. Tribes hold a unique Government-to-Government
relationship with the U.S. [refer to OTASA Fact Sheet for more
information])
Avoid saying target, tackle, combat, or other Tackle a community’s health issue Engage
terms with violent connotation when referring to Target communities for Prioritize
people, groups, or communities. interventions Consider the needs of/Tailor to the needs of
Population of focus
Stakeholder (Note: this term has a particularly Stakeholder Note: Stakeholders are persons who may be affected by a
violent connotation for tribes and urban Indian Stakeholder engagement course of action. Preferred terms include community
organizations) members and persons affected by [policy/program/practice].
Also avoid using stakeholder to mean partner; related terms
to use include partners, collaborators, allies, community
engagement, tribal engagement, urban Indian conferment
(contact OTASA for technical assistance).

Table 2. Preferred terms for select population groups and communities

Topic area/Population Terms to avoid Preferred terms
Corrections Inmate; prisoner; convict; ex-convict; People/persons who are incarcerated or detained; individuals/people/persons
offender; criminal; parolee incarcerated or detained (often used for shorter jail stays; youth in detention
facilities); incarcerated or detained persons; persons in pre-trial or with charge;
justice-involved persons; formerly incarcerated persons; persons on parole or
probation; non-US citizens (or immigrants) in immigration detention facilities.
Disability Disabled; differently-abled; handicapped People with disabilities/a disability; people/persons who are deaf or hard of
(also avoid using “vulnerable” when hearing or who are blind or have low vision; people/persons with an intellectual
describing people with disabilities) or developmental disability; people/persons who use a wheelchair. See
Communicating With and About People with Disabilities.
Note: CDC is aware that some individuals with disabilities prefer to use identity-
first terminology, which means a disability or disability status is referred to first;
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Topic area/Population Terms to avoid Preferred terms
for the purposes of this guide, CDC is promoting person-first language but also
acknowledges that personal preferences vary.
Drug/substance use Drug-users; addicts; drug abusers; persons Persons who use drugs; people who inject drugs; persons with substance use
taking/prescribed medication assisted disorder; persons with alcohol use disorder; persons in recovery from substance
treatment (MAT); persons who relapsed use/alcohol disorder; persons taking/prescribed medications for opioid use
disorder (MOUD); persons who returned to use
Healthcare access Underserved people; the underserved; People who are underserved; people who are medically underserved; people
hard to reach; the uninsured without health insurance; Note: “Underserved” relates to lack of access to
services, including healthcare. Do not use “underserved” when you really mean
“disproportionately affected.” Use person-first language.
Homelessness Homeless people; the homeless; transient People experiencing homelessness; persons experiencing unstable
population housing/housing insecurity; persons who are not securely housed
Lower socioeconomic Poverty-stricken; the poor; poor people People with lower incomes; people/households with incomes below the federal
status poverty level; people with self-reported income in the lowest income bracket (if
income brackets are defined); people experiencing poverty (do not use
“underserved” when meaning low SES)
Note: “People with lower levels of socioeconomic status” should only be used
when SES is defined (e.g., when income, education, and occupation are used as
a measure of SES).
Non-U.S.-born persons; • Alien; illegals; illegal immigrant • People who are undocumented; undocumented immigrants; non-status
immigration status immigrants; mixed-status households; unauthorized immigrants (for technical
documents – otherwise, undocumented immigrants is preferred); asylee or
refugee populations
• Immigrant (not to be used to refer to • Non-US-born persons; foreign-born persons; naturalized citizens; permanent
undocumented immigrants specifically) residents; non-immigrants (persons with a temporary visa)
Note: It is appropriate to use the term “immigrant” to refer only to those who
are Lawful Permanent Residents (i.e., those with a “Green Card”), however, it
should be clarified that the term is only referring to that population.
Sexual and gender Avoid referring to persons or communities Refer to persons or communities (e.g., transgender persons) as:
minorities as: • LGBTQ (or LGBTQIA or LGBTQ+); lesbian; gay; bisexual; queer; pansexual;
• Homosexual asexual
• MSM (men who have sex with men) Note: Use LGBTQ community (and not, e.g., gay community) to reflect the
diversity of the community unless a specific sub-group is meant to be
referenced.
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Topic area/Population Terms to avoid Preferred terms
• Transgenders; transgendered; • Transgender; assigned male/female at birth; designated male/female at birth;
transsexual; biologically male/female; gender non-conforming; non-binary; genderqueer
genetically male/female
• Hermaphrodite • Intersex
Note: Avoid using the term sexual Note: Preferred terminology includes sexual orientation, gender identity, and
preference. gender expression.
Older adults Elderly; senior; frail; fragile Older adults (aged ≥ 65 years); numeric age groups (e.g., persons aged 55-64
years)
People who are at High-risk people; high-risk population; People who are at increased/higher risk for [condition]; people who live/work
increased/higher risk vulnerable population; priority in settings that put them at increased/higher risk of becoming infected or
populations exposed to hazards; populations/groups disproportionately affected by
[condition]; populations/groups highly affected by [condition]
Pregnancy Pregnant women; mothers-to-be; Use terms that are inclusive of all gender identities:
expectant mothers Pregnant people; parents-to-be; expectant parents
Race and ethnicity • Referring to people as their Preferred terms for specific racial/ethnic groups:
race/ethnicity (e.g., Blacks, Hispanics, • American Indian or Alaska Native persons
Latinos, Whites, etc.) Asian persons
• Indian (to refer to American Indian); Black or African American persons
Eskimo; Oriental; Afro-American; Negro; Hispanic or Latino persons
Caucasian Native Hawaiian or other Pacific Islander persons
• the [racial/ethnic] community (e.g., the White persons
Black community) People who identify with more than one race/ethnicity; people of more than
• non-White (used with or without one race/ethnicity
specifying non-Hispanic) Note: Black and White should be capitalized.
Note: “American Indian or Alaska Native” should only be used to describe
persons with different tribal affiliations. Otherwise, identify persons or groups
by their specific tribal affiliation.
Preferred terms for groups including 2 or more racial/ethnic groups:
• People from some racial and ethnic minority groups
• People/communities of color
Note: Only used to collectively refer to racial and ethnic groups other than
non-Hispanic White; be mindful to refer to a specific racial/ethnic group(s)
instead of this collective term when the burden and experience of disease is
different across groups.
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Topic area/Population Terms to avoid Preferred terms
Note: The term “Indian Country” describes reservations, lands held within tribal
jurisdictions, and areas with American Indian populations.
• All other races; all other races/ethnicities; racial and ethnic minority groups
(instead of non-White)
See OMB standards.
See AMA Manual of Style guidance on use of the words Tribe and Tribal.
Note: It is critical to recognize the sovereignty of Alaska Native and American
Indian tribes and tribal organizations. All related materials require tribal
permission. All AIAN specific publications including abstracts, papers, ppts,
require CSTLTS cross-clearance. See CDC/ATSDR Tribal Consultation Policy.
Rural Rural people; frontier people People who live in rural/frontier areas; residents/populations of rural areas;
rural communities

Table 3. Health equity considerations for developing community mitigation guidance and public health
communications
Topic area/Population Health equity considerations
Overarching • Build a diverse workforce throughout levels, including leadership positions; consider the benefits of hiring people from
considerations the communities who are disproportionately impacted.
• Work with community partners to identify priorities and strategies, including the need to build community awareness
and acceptance.
• Ensure information is written in plain language, culturally responsive, and available in languages that represent the
communities.
Images used in • Images for social media, websites, etc. should focus on movement toward health equity, empowerment, and a collective
communications approach to resolving issues. Images of positive health-related activities and people working together would be more
suitable.
o People of color should be proportionately represented in appropriate images; however, images should avoid
unintentionally messaging that the efforts to address disparities are the sole responsibility of the people experiencing
the disparities.
o For people with disabilities, consider using positive photos of people with disabilities in health communication
materials including social media posts.

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Topic area/Population Health equity considerations
Considerations to improve • Insufficient consideration of culture in developing materials may unintentionally result in misinformation, errors,
cultural responsiveness confusion, or loss of credibility. Please check materials for the following:
o Are there words, phrases, or images that could be offensive or stereotypic of the cultural or religious traditions,
practices, or beliefs of the intended audience?
o Are there words, phrases, or images that may be confusing, misleading, or have a different meaning for the intended
audience (e.g., if abstract images are used, will the audience interpret them as intended)?
o Are there images that do not reflect the look or lifestyle of the intended audience, or the places where they live,
work, or worship?
o Are there health recommendations that may be inappropriate for the social, economic, cultural, or religious context
of the intended audience?
o Are the toll-free numbers or reference web pages, when applicable, included in the document in the language of the
intended audience?
• These considerations and others should be reviewed again when material is translated.
Considerations of ability to • Ability to isolate or quarantine varies by household characteristics and congregate facility configuration; it is more
follow guidelines difficult as the numbers of affected individuals (or cohorts) increases.
• Self-isolation or self-quarantine is not an option for all persons.
• Ability to isolate or quarantine at home may not be possible, especially for persons experiencing homelessness or
crowded housing.
• Overcrowding and congregate housing settings makes social distancing difficult or infeasible.
• Access to hand washing supplies, including running water, and masks can vary.
• Not everyone has a regular healthcare provider. Additionally, not everyone trusts medical professionals, so guidance to
have and talk with a regular PCP might not be accepted.
• Access to medical and mental health care and needed services (e.g., social services, preventive screenings, syringe
service programs) might be limited. Access during an epidemic might further reduce access, and some clinics may be
closed or have limited hours or alternate services available.
• Wearing masks is not possible for many persons. Children younger than 2 years old, anyone who has trouble breathing,
and anyone who is unable to remove the mask without assistance should not wear a mask. Wearing a mask precludes
the ability to read lips and facial expressions for people with sensory, cognitive, or behavioral limitations.
Disability • People with disabilities comprise 26% of the U.S. adult population, so considerations should be included in most
guidance.
• Information should be made available in accessible formats (e.g., meet 508 compliance standards, large print, Braille,
American Sign Language, close captioning, audio descriptions, plain language) for people with vision, hearing, cognitive,
and learning disabilities. Many of these communication formats also benefit individuals without disabilities.
• Ensure equal access to public health services for people with disabilities and operation of disability services before,
during, and after public health emergencies.
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Topic area/Population Health equity considerations
Older adults • Age and associated risk are often a continuum.
• Risk for severe COVID-19 outcomes increases with age, with increasing risk among middle-aged adults, and older adults
being at highest risk.
• Guidance should be tailored to specific setting of interest within this age group (e.g., community dwelling; those living
in multigenerational homes; those living in long-term care facilities or nursing homes; those living in retirement homes).
• COVID-19 signs and symptoms may sometimes be atypical, delayed, or attenuated in older adults.
• Consider risks to caregivers of older adults as well; caregivers themselves are often older adults or may have other risk
factors.

Table 4. Resources and style guides for framing health equity and avoiding stigmatizing language
Source Link Summary
American Medical Association (AMA) Use of the words Tribe and Tribal Considerations for using/capitalizing the terms Tribe and Tribal
American Psychological Association (APA) Bias-Free Language 10 sections, including age, disability, gender, racial and ethnic
identity, sexual orientation, and socioeconomic status
American Public Health Association Health Equity APHA Health Equity Fact Sheets
Build Healthy Places; RWJF Terms that Often Arise in Discussions Brief to stimulate discussion and promote greater consensus about
of Health Equity the meaning of health equity and the implications for action within
the RWJF Culture of Health Action Framework
CDC/NCBDDD Communicating With and About Preferred (person-first) terms for person/people with a disability
People with Disabilities
CDC/NCIPC Commonly Used Terms Definition of terms related to drug/substance use; preferred terms
FrameWorks Institute Talking About Disparities: Description of framing strategies that do and do not work to
The Effect of Frame Choices on improve support for policies related to race/ethnicity
Support for Race-Based Policies
GLAAD GLAAD Media Reference Guide Definition of LGBTQ terminology and terms to avoid
HHS 508 compliance Accessibility @ HHS HHS’ role in accessibility – Includes compliance checklist, Office of
the Secretary Accessibility Program, and other resources
Office of Management and Budget OMB standards Revisions to the Standards for the Classification of Federal Data on
Race and Ethnicity
Robert Wood Johnson Foundation A New Way to Talk About the Social Guidance on framing the issues related to social determinants of
Determinants of Health health
Emerging Infectious Diseases Journal Preferred usage Preferred usage for terms and group descriptions
University of New Hampshire - University Person first Language A partial glossary of disability terms
Center on Disability
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Glossary
While there are variations on health equity definitions, CDC’s Office of Minority Health and Health Equity (OMHHE) defines health equity as the
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 healthcare disparities.1 Specifically, it
requires prioritizing addressing obstacles to health, such as poverty, discrimination, and their consequences, including lack of access to good jobs with
fair pay, quality education and housing, safe environments, and health care.2 For the purposes of measurement, OMHHE recognizes that health equity
means reducing and ultimately eliminating disparities in health and its determinants that adversely affect groups that have been excluded or
marginalized, and that these groups are not static over time.2 Below we briefly define other select terms based on various resources.

Discrimination: The unjust or prejudicial treatment of different groups of people, including by age, disability, ethnicity, gender, national origin, race,
religion, sexual orientation, or other characteristics. Discrimination exists in systems meant to protect well-being or health, such as health care, housing,
education, criminal justice, and finance. Discrimination can lead to chronic and toxic stress and shapes social and economic factors that put some people
at increased risk for adverse health outcomes. Types of discrimination include ableism, ageism, homophobia, racism, and sexism.

Diversity: An appreciation and respect for the many differences and similarities in our work. This includes varied perspectives, approaches, and
competencies of coworkers, partners, and populations we serve.

Health disparity: A particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage other
characteristics historically linked to discrimination or exclusion. Health disparities adversely affect groups of people who have systematically experienced
greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or
physical disability; sexual orientation or gender identity; or geographic location.

Health inequity: A health difference or disparity that is unfair, unjust, and avoidable.3,4

1
U.S. Department of Health and Human Services, Office of Minority Health. National Partnership for Action to End Health Disparities. The National Plan for Action Draft
as of February 17, 2010 [Internet]. Chapter 1: Introduction. Available from: http://www.minorityhealth.hhs.gov/npa/templates/browse.aspx?&lvl=2&lvlid=34.
2
Braveman P, Arkin E, Orleans T, Proctor D, and Plough A. What is Health Equity? And What Differences Does a Definition Make? Princeton, NJ: Robert Wood Johnson
Foundation, 2017.
3
Braveman P. Health disparities and health equity: concepts and measurement. Annu Rev Public Health. 2006;27:167-94. Review. PubMed PMID: 16533114.
4
Braveman P, Gruskin S. Defining equity in health. J Epidemiol Community Health. 2003 Apr;57(4):254-8. Review. PubMed PMID: 12646539; PubMed Central PMCID:
PMC1732430.
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Inclusion/Inclusivity: A set of behaviors that authentically encourages individuals to feel valued for their unique qualities and experience a sense of
belonging and shared power. Inclusive diversity is a set of behaviors that promote collaboration within a diverse group.

Intersectionality: The interconnected nature of social categorizations such as race, class, and gender as they apply to a given individual or group,
regarded as creating overlapping and interdependent systems of discrimination or disadvantage.5

Privilege: Unearned advantage, immunity, and social power held by members of a dominant group.

Racism: A system of structuring opportunity and assigning value based on the social interpretation of how one looks (which is what we call "race"), that
unfairly disadvantages some individuals and communities, unfairly advantages other individuals and communities, and undermines realization of the full
potential of our whole society through the waste of human resources. Racism can be expressed on three levels:6
Interpersonal/personally-mediated racism: Prejudice and discrimination, where prejudice is differential assumptions about the abilities,
motives, and intents of others by “race,” and discrimination is differential actions towards others by “race.” These can be either intentional or
unintentional.
Systemic/institutionalized/structural racism: Structures, policies, practices, and norms resulting in differential access to the goods, services, and
opportunities of society by “race” (e.g., how major systems– the economy, politics, education, criminal justice, health, etc. – perpetuate unfair
advantage).
Internalized racism: Acceptance by members of the stigmatized “races” of negative messages about their own abilities and intrinsic worth.

Social determinants of health: 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.7

Social exclusion or marginalization: A complex, multi-dimensional (economic, political, social, and cultural) process when certain social groups have
barriers to full participation in society that prevent them from sharing the benefits of participation, affecting equity and social cohesion; places where
they live often have health-damaging lack of opportunities, access to resources, voice, or respect for rights (e.g., lack of access to jobs and inadequate
schools).8

5
Oxford Dictionary. https://www.lexico.com/en/definition/intersectionality
6
Jones CP (2002). Confronting institutionalized racism. Phylon (1960-), 7-22.
7
Healthy People 2020 Social Determinants of Health. https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health
8
UN. Leaving No One Behind. Chapter 1: Identifying social inclusion and exclusion. https://www.un.org/esa/socdev/rwss/2016/chapter1.pdf
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Stigma: Stigma is discrimination against an identifiable group of people, a place, or a nation. Stigma is associated with a lack of knowledge, a need to
blame someone, fears about disease and death, and gossip that spreads rumors and myths.9

Stigmatizing language: Language that implicitly contains a negative judgement about the character of a person or a group of people. It also may blame
people for circumstances beyond their control. Such language often contributes to disapproving views of, or discrimination against, a group of people.

9
CDC. Reducing Stigma. https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/reducing-stigma.html
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