The Strategic Framework Preface Introduction Background on the Framework The Strategic Framework Next Steps Conclusions References Complete Framework (print version)
In this section...Framework Begin with Long-Term Problems Address Contributing Factors Support Effective Strategies and Practices Measure Intermediate Outcomes Achieve Long-Term Objectives and Goals

III. The Strategic Framework

The Framework is presented in five sections, organized sequentially into the components presented in the graphic depiction of its general structure shown in Figure 1. Each component of the Framework, and the corresponding step toward its development, is discussed separately. The major elements within each of these sections are drawn from the literature and briefly outlined and discussed below.

Step 1: Begin with Long-Term Problems

There are two sets of long-term problems that OMH and its partners must continue to address: (1) racial and ethnic minority health problems and (2) systems issues that inhibit the ability to effectively impact racial/ethnic minority health problems. These long-term problems are depicted graphically in Figure 2.

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Figure 2. Long Term Problems.

• Racial and ethnic minority health problems fall into two categories: racial/ethnic minority health status and, related to that, racial/ethnic health disparities. Racial/ethnic minority health status problems encompass preventable morbidity and premature mortality experienced by racial and ethnic minority individuals and groups without reference to others. Racial and ethnic health disparities entail differences in health status and health care that often reflect a greater burden of morbidity and mortality on racial and ethnic minorities as compared to the majority population.
  
• Systems issues encompass a wide variety of conceptual, organizational, structural and process-related variables that influence the ability to adequately and effectively address complex problems - and that can exacerbate these problems, or constitute problems in their own right. These variables include the availability of adequate resources to support the systems and the strategies and practices aimed at the problems and contributing factors, the extent to which systems support strategies and practices that are evidence-based as well as systematic planning and evaluation of actions undertaken, the extent to which the systems (and the strategies/practices) are well-coordinated and strategically directed, and the extent to which existing stakeholder groups are willing to work together as parts of an interconnected system. This need for a 'systems approach' and systematic actions applies broadly across all efforts conducted for the purpose of improving minority health and reducing health disparities. It also applies specifically to research and evaluation efforts to address gaps and weaknesses in science and knowledge about the nature and extent of racial and ethnic minority health problems and effective solutions to such problems.

The two racial/ethnic minority health issues–health status and health disparities–parallel and link to the two principal goals of Healthy People 2010 . (HHS, 2000b) Thus, success in addressing racial/ethnic minority health issues will contribute to the achievement of the two central goals of Healthy People 2010 .

Step 2: Address Contributing Factors

Since the factors contributing to poor racial/ethnic minority health–and to racial/ethnic health disparities–are many and complex, they have been organized into three categories or levels : individual-level factors, environmental-/community-level factors and systems-level factors.

• Individual-level factors include the knowledge and attitudes that individuals have about health risks, disease prevention, and treatment, the skills that individuals have to put knowledge into practice, the individual behaviors that have an impact on one's own health or the health of others, and the genetic factors that may enhance or reduce individual susceptibility to particular health conditions. In the graphic representation of the contributing factors component of the Framework (see Figure 3), individual-level factors are identified as knowledge, attitudes, skills, behaviors and biological or genetic risks.
  
• Environmental- and community-level factors include the physical environment (both natural and built), social and cultural characteristics of a community, and other economic, political and organizational/institutional conditions that are not generally within the control of specific individuals but provide the context of their lives. These factors may be either protective of, or pose risks to, health. Such factors include, but are not necessarily limited to: natural and physical hazards or biochemical risks, crime and violence, cultural values and norms that influence individual behavior and can protect or hinder the health and well-being of residents within communities, bias and discrimination, housing conditions and residential segregation, access to and quality of health care as well as schools, parks and recreational sites, nutritious food sources, transportation and other goods and services, communication networks and infrastructure, family and social networks or other supports for diverse segments of the community, low-income and poverty, unemployment, and the lack of health insurance. For purposes of framework development, environmental- and community-level factors are divided into those related to the physical environment, the social environment or economic barriers, with the social environment subdivided into community values, community assets or community involvement (see Figure 3). (Note: Because these factors are so complex and interrelated, many public health and social science researchers investigate and discuss such factors in combination, rather than as the discrete categories that are shown in this particular framework. The literature (see, for example, Kawachi, Kennedy, and Wilkinson, 1999) is replete with examples of the associations between socioeconomic status (SES) and morbidity/mortality–and the significant implications of SES for health. While problems related to low SES also affect White populations, the greatest impact is on racial/ethnic minorities who are overrepresented in the lower socioeconomic categories.)
  
• Systems-level factors include the kinds of systems that a community, state, region or nation might have (or not have), and approaches used (or not used), for identifying the problems or needs– health-related or otherwise–in their respective jurisdictions and for directing resources to address the problems or needs. Whether such systems and approaches (including public health and health care systems and approaches) effectively address such problems or needs depends upon the presence or absence of certain factors that are characteristic, or key components, of systems-oriented, systematic and strategic thinking and actions. These systems-level factors include, but are not limited to: the adequacy, appropriateness and mix of components, resources and assets; the effectiveness of efforts to configure, coordinate, and leverage such components, resources and assets, the extent to which leadership and commitment are provided to direct and sustain the components and the use of resources and assets, especially as guided by a vision and a strategic plan, the nature and extent of information- and knowledge-sharing and supportive infrastructure, the extent to which systems–and the products or services provided by such systems–are designed, implemented and evaluated with the needs of their users and beneficiaries in mind, and the continued, coordinated and effective production of research and evaluation results that are widely shared and adopted for continuous improvement. As depicted in Figure 3, in the strategic framework, systems-level factors are organized into five major categories: components and resources, coordination and collaboration, leadership and commitment, user-centered design and science and knowledge.

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Figure 3. Contributing factors.

These three levels, or sets, of factors interact to form the context for considering health outcomes in general (see Evans and Stoddart, 1990; Green and Kreuter, 1999; Green, Potvin, and Richard, 1996), including those specific to racial/ethnic minority health improvement and health disparities reduction. A good example of an interacting factors model that is organized into levels or categories is the Determinants of Health Model in Healthy People 2010 (HHS, 2000c). In this model, key categories or factors include biology, behavior, social environment, physical environment, policies and interventions and access to quality health care. The determinants, or factors, approach to health is used herein to synthesize some of what the literature, research and expert opinion have identified as the key factors that contribute to racial/ethnic minority health problems and disparities in health status and health care. (Note: Approaches to population health that describe relationships and interactions between multiple determinants of health at the individual and environmental/community levels and how they affect health or illness are sometimes referred to as "ecological models" of health.)

Step 3: Support Effective Strategies and Practices

The contributing factors identified above form the basis for the targets to be addressed by a range of strategies and practices employed by OMH and its partners. The strategies and practices discussed in this document represent what current evidence and expert consensus suggest to be successful in impacting contributing factors. Those strategies and practices that address the contributing factors and fit into OMH's mission are emphasized. It is important to note that many of the strategies and practices may address several factors at the same time or in sequence, rather than only one factor. A number of strategies and practices are also often effectively combined with others, in more comprehensive approaches. In a number of cases, new strategies or practices need to be developed and tested, as guided by available science and practice. Figure 4 is a graphic depiction of the necessary relationship between the strategies and practices supported and the individual-, environmental-/community-, and/or systems-level factor(s) that cause or contribute to the problem(s) to be solved.

• Strategies and Practices to Address Individual-Level Factors – Approaches that address individual-level factors include efforts to increase knowledge, promote positive attitudes, and improve skills that affect decisions about health-related behavior. A broad range of informational/educational methods and materials, dissemination channels and venues may be used (e.g., written materials, including popular and professional publications, radio and television broadcasts, computer- and web-based technologies, mass media campaigns, and one-on-one or group-oriented education, counseling and training in schools, clinics, worksites and community settings). With respect to biological and genetic risks, individual-level efforts include informational, screening and counseling strategies and practices. Strategies and practices may be aimed at a variety of individuals and groups of individuals, including, but not limited to, those who are racial/ethnic minorities themselves, those meeting some other particular characteristic (e.g, age range, gender, health literacy level) and those who interact with or serve minorities (e.g., health care providers). Effective efforts tend to reflect integrated approaches that address a combination of individual-level factors as well as their interactions with environmental factors that inhibit or support desired behaviors. In addition, health messages are more readily accepted if they do not conflict with existing cultural beliefs and practices, and take into account unique historical and cultural experiences of target audiences, including racial and ethnic minorities. [D]
  Figure 4. Strategies and Practices.
  
• Strategies and Practices to Address Environmental- and Community-Level Factors - The strategies and practices included in this category are aimed at those factors that extend beyond individuals, and shape the broader communities and environments within which people live, work and play. Examples of such efforts are: (1) promotion of a healthy physical environment through the development of policies that promote public health and safety, (2) fostering of a positive social environment by nurturing community values and norms conducive to good health, strengthening community capacity and "assets" for general well-being, and/or increasing community involvement, supports and networks (i.e., "social capital") via opportunities for civic engagement and positive social interaction that promote self-reliance, buffer stress and otherwise protect the health and well-being of diverse members in the community, and (3) provision of health care financing and other initiatives that provide support to poor, low-income and underserved populations (e.g., children's health insurance for low-income families, implementation of prescription drug coverage for Medicare beneficiaries). Many other program efforts have tried to link multiple community-based strategies and practices together to address the interactive nature of all of the environmental- and community-level factors influencing health.
  
• Strategies and Practices to Address Systems-Level Factors – A review of systems literature and a research synthesis of "effective" public health and health care systems found that effective systems aimed at complex problems have certain characteristics in common. The systems-level strategies and practices recommended in the Framework include efforts to:
  
  • Establish, increase and strengthen system components and resources, such as infrastructure, staffing and funding to ensure specific attention to racial/ethnic minority health and health disparities. This often involves obtaining resources from mixed funding streams in order to leverage assets and expand the resource base.
    
  • Promote coordination, collaboration and partnerships to build relationships and trust, allow for pooling and leveraging of resources, expertise and talent, and foster synergies that benefit all involved parties. Such coordination and collaboration requires strong information and communications systems and infrastructure.
    
  • Foster and ensure leadership and commitment, including the development and implementation of strategic plans that provide vision and direction, set priorities and coordinate and target resources. Ideally, strategic plans for addressing minority health and health disparities should draw on existing data on minority groups, incorporate input and feedback from community partners, build upon the best of existing and emerging evidence of successful strategies and practices, structure activities around expected outcomes and impacts tied to goal-setting processes (e.g., Healthy People 2010 ) at the State and Federal levels, and employ performance assessment and evaluation results for continuous improvement. Legislative or regulatory initiatives, executive orders and other administrative mandates comprise another important set of strategies for ensuring sustained attention and commitment to minority health and health disparities issues.
    
  • Promote user-centered design to address racial/ethnic minority needs
    Racial/ethnic minorities may be disproportionately impacted by such experiences as lack of access to the public goods and services that are important for health and well-being, limited health care coverage or the inability to pay for health services, lack of trustworthiness on the part of health care and research institutions, racial/ethnic bias or discrimination, cultural and linguistic barriers, and lack of respect because of racial, ethnic, cultural or linguistic differences. Recommended strategies and practices to address these concerns include efforts that: increase participation of racial/ethnic minorities in planning, implementation, monitoring and evaluation of programs and initiatives intended to meet their needs (i.e., community-based participation), increase health care access and coverage, increase availability of culturally and linguistically appropriate services (CLAS), increase workforce diversity, and improve the collection, analysis and use of racial and ethnic data for performance monitoring and quality improvement purposes.
    
  • Improve science and knowledge about successful strategies and practices through increased and enhanced research, demonstrations and evaluation (RD&E). This includes RD&E efforts that strengthen knowledge and understanding about: the nature and extent of minority health/health disparities problems, especially for small or hard-to-reach populations for which data continue to be lacking, the mechanisms by, and extent to, which systems factors inhibit the ability to address minority health and health disparities, the relative importance of the various factors that cause or contribute to the long-term problems and how interactions between these factors promote or inhibit health, effective interventions that not only improve racial/ethnic minority health, but actually reduce racial/ethnic health gaps among populations, effective systems and evidence-based systems approaches to addressing minority health/health disparities problems, and effective methods for disseminating results of research, "translating research into practice and policy" and "putting practice into research" (making research results "practitioner-centered"). Transdisciplinary approaches to research, which can inform more multi-faceted solutions to the long-term problems at hand are also emphasized.

Step 4: Measure Intermediate Outcomes and Long-Term Impacts

This step identifies measurable outcomes and impacts that might be expected to take place following implementation of the indicated strategies and practices. Such outcomes and impacts relate to the contributing factors. Generally, outcomes refer to short-term results (e.g., increased awareness and knowledge about disease prevention or risk reduction) and impacts refer to long-term results (e.g., reduced morbidity or mortality). The outcomes and impacts include those for which there is actual research evidence as well as those based on expert judgment.

In many current efforts to address racial/ethnic minority health and health disparities problems, the strategies and practices have not been clearly tied to desired or intended outcomes and impacts. Nor have adequate and appropriate evaluations been performed to determine if, indeed, the strategies and practices produce meaningful results. This is a major shortcoming. It is necessary to structure future minority health and health disparity efforts so that they will be more health outcome- and impact-oriented. It is also important to determine the outcomes and impacts of systems-oriented strategies and practices on efforts to affect health outcomes and impacts. Identifying the outcomes and impacts expected from programmatic and policy-oriented minority health/health disparities efforts–as well as systems approaches to addressing minority health/health disparities issues–will inform, and be informed by, future research and evaluations. The Framework identifies and organizes a range of outcomes and impacts that might be expected, with reference to the contributing factors and the strategies and practices already discussed. These outcomes and impacts are organized into three categories, or levels, as depicted in Figure 5.

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Figure 5. Outcomes and Impacts

A wide range of short-term, intermediate and longer-term outcomes and impacts are possible and desirable at the individual, environmental/community and systems levels to move OMH and other stakeholders toward long-term objectives and goals. The desired or expected results are dependent upon the kinds of strategies and practices being planned and implemented, the factors and problems to be affected, the populations being targeted and the settings in which interventions are taking place. Some examples of the general outcomes and impacts that might be produced by the strategies and practices are outlined below.

Individual-Level Outcomes and Impacts

• Increased awareness/knowledge about disease prevention, risk reduction and treatment and management for racial/ethnic minorities
  
• Improved attitudes/beliefs conducive to health and health-seeking behaviors among racial/ethnic minorities
  
• Improved attitudes/beliefs among health care/human service providers and researchers conducive to meeting the needs of racial/ethnic minorities
  
• Increased skills for racial/ethnic minorities to adopt healthy lifestyle behaviors
  
• Increased skills for public health/health care providers and other service professionals to provide culturally and linguistically appropriate services (CLAS)
  
• Increased patient satisfaction with patient-provider communications and interactions.
  
• Increased patient adherence to prescribed treatment regimens
  
• Increased engagement in/adoption of healthy lifestyle and appropriate health-seeking behaviors; reduced engagement in/adoption of risky behaviors
  
• Reduced morbidity and mortality

Environmental- and Community-Level Outcomes and Impacts

• Decreased exposure to risks in the physical environment
  
• Increased awareness/knowledge about racial/ethnic minority health problems and racial/ethnic health disparities among racial/ethnic minorities, among public health/health care providers and service professionals and in the general public
  
• Increased health-conducive changes in community attitudes, values and norms
  
• Increased community assets that are protective of the health and well-being of its residents (e.g., health centers in underserved communities, neighborhood restaurants and grocers with healthy food options, faith-based organizations, gathering places)
  
• Increased number of active organizations and family or social networks that meet the social needs and promote the general health and well-being of racial/ethnic minority populations in the community (e.g., church groups, social clubs, recreational and after-school programs)
  
• Increased health care access and appropriate utilization
  
• Increased number of plans and policies that promote and protect health and well-being at the community, state and national levels, in general, and for racial/ethnic minorities, in particular
  
• Increased engagement in/adoption of healthy lifestyle and appropriate health-seeking behaviors, reduced engagement in/adoption of risky behaviors
  
• Reduced morbidity and mortality

Systems-Level Outcomes and Impacts

• Increased inputs, assets and other resources allocated for racial/ethnic minority health and health disparities–in general and for specific priorities
  
• Increased dedicated assets and other resources for minority health/health disparities (including, but not limited to, state offices of minority health) and related priorities (as reflected in administrative, legislative, budgetary and other mandates)
  
• Increased formal partnerships and collaboration leading to coordination/leveraging of resources for greater efficiency, and enhanced effectiveness of minority health/health disparities initiatives
  
• Increased strategic planning and implementation of plans, with clearly articulated goals and objectives, for racial/ethnic minority health improvement and health disparities reduction
  
• Increased integration of evaluation, performance measurement and monitoring, and continuous improvement in planning and implementation of racial/ethnic minority health and health disparities efforts
  
• Increased collection, dissemination and use of racial/ethnic data for planning, quality assurance and performance monitoring/improvement purposes (e.g., to assess whether clinical care guidelines for specific diseases are being employed consistently and appropriately, to address health care disparities)
  
• Improved system design characteristics that are directed to specific racial/ethnic minority health needs, such as the need to address cultural and linguistic differences, promote trust and trustworthiness, etc., (with measures that focus on, for example, increased involvement/participation of racial/ethnic minorities or representatives in health care quality and research initiatives, increased adoption of CLAS standards by health plans, and/or increased diversity in the public health/health care workforce)
  
• Increased knowledge development/science base about successful strategies and practices for improving racial/ethnic minority health and reducing health disparities
  
• Increased dissemination and diffusion of evidence-based strategies and practice to improve racial/ethnic minority health and reduce health disparities
  
• Increased formal partnerships and collaboration across research disciplines leading to coordination/leveraging of research dollars and more multi-faceted approaches to impacting factors that contribute to poor racial/ethnic minority health outcomes and health disparities
  
• Increased and improved outcomes and impacts at the individual and environmental/ community levels

The identification of expected outcomes and impacts is an important part of the planning, implementation and evaluation processes needed in minority health- and health disparities-related efforts conducted or supported by OMH and its partners. Once desired or expected outcomes and impacts are identified, the process of determining performance measures or indicators of progress in achieving such outcomes and impacts can occur. With the identification and selection of performance measures or indicators of the expected outcomes or impacts, the effectiveness of the strategies and practices in producing the desired results can then be evaluated. Hence, the identification of outcomes and impacts within the strategic framework becomes the basis for identifying and developing performance measures as well as the kind of evaluation needed to promote an outcome or results orientation in the efforts being funded or otherwise supported by OMH and other stakeholders.

Step 5: Achieve Long-Term Objectives and Goals

An important part of the strategic framework is its focus on long-term objectives and goals, including those in Healthy People 2010. (Note: OMH encourages and supports efforts that contribute to the long-term objectives and goals specified in Healthy People 2010, especially those that are of particular relevance to racial/ethnic minority populations and systems-related priorities.) OMH, states, communities and other stakeholders can use this framework to guide the selection of problems, factors and strategies/practices that can be linked to short-term, intermediate- and long-term objectives and goals, based on identified outcomes and impacts. And, as shown in Figure 6, these objectives and goals can be set, if desired, for the individual, environment/community and/or systems level(s). With the collection of the appropriate output, outcome and impact data, stakeholder organizations can evaluate the extent to which the objectives and goals have been attained.

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Figure 6. Long-Term Objectives and Goals.

To the extent that strategies and practices result directly or indirectly in impacts on the determinants of health, and achieve health outcomes, more progress will be made toward the long-term goals of improving racial/ethnic minority health and eliminating racial/ethnic health disparities. Such efforts will necessitate a systems approach and a concerted effort to build and deploy evidence-based practice in order to promote continuous improvement based on coordinated and strategic application of the most current science and knowledge and to mobilize the resources and talents of all stakeholders.