IV. Next Steps: Using the Framework to Support Evaluation and Evidence-Based Practices
The Framework clearly identifies five steps that must be taken to ensure that strategies and practices aimed at improving racial/ethnic minority health and reducing racial/ethnic health disparities are effective. The five steps include: (1) identify the long-term problems, (2) identify the key factors that contribute to those long-term problems, (3) identify or develop strategies and practices that effectively address the contributing factors and the long-term problems, (4) identify expected outcomes and impacts and determine appropriate measures or indicators of such results, and (5) document progress in achieving agreed-upon objectives and goals. The Framework highlights many of the relationships between and among these five steps, and suggests a variety of ways in which the Framework can be used at a national, state, Tribal, regional or local level.
While health status is the ultimate measure of health disparities, the intermediate outcomes–representing key steps along the path toward greater equity in health care and health status–must be based on the kind of rationale and model presented in this document. This is a model that explicitly encompasses the full range of multiple and complex factors that contribute to poor health for many racial/ethnic minorities and high levels of racial/ethnic health disparities. This model is unique in that it includes the need for a "systems approach" to addressing racial/ethnic minority health problems (i.e., working together as an interconnected system) and the lack of systematic planning, implementation and evaluation of current efforts as a separate set of long-term problems that can have profound and persistent impacts on racial/ethnic minority health status and health disparities. Given their great importance, these systems issues must be addressed as problems in their own right, with attendant strategies and practices that are already proven or that need to be developed and rigorously evaluated. Improvements in systems that have population-wide scope can accelerate progress.
The strategic framework is simply structured, and its structure permits flexibility in its application by various stakeholders to different situations and for different purposes. First and foremost, the Framework can be used by OMH, other HHS entities and HHS partners to focus programmatic and policy-oriented actions that are based on existing science and knowledge about the problems and contributing factors to be addressed and about strategies and practices known to be effective in producing desired outcomes and impacts. Secondly, the Framework can also provide the basis for a protocol to systematically evaluate OMH-funded and other activities in a way that produces more consistent information on what grantees and others are actually doing to improve racial/ethnic minority health status and reduce racial/ethnic health disparities. (Note: As part of its Spring 2007 grant cycle, OMH issued its new Evaluation Planning Guidelines for Grant Applicants to strengthen evaluation within its grant programs. These guidelines were informed by the strategic framework and serve as the preliminary version of OMH's evaluation protocol for its state-based and other funded efforts.)
In addition, through more systematic and rigorous research and evaluation, the Framework can facilitate more targeted and efficient methods for identifying and developing best or evidence-based practices, and can strengthen the justification for directing resources toward such efforts. Any effort to identify best practices, however, requires a set of criteria by which to make that judgment. The work of established, respected, scientific expert bodies within and outside of HHS–such as, the U.S. Preventive Services Task Force, the Task Force on Community Preventive Services, and the British-based Cochrane Collaboration–can inform this process. Both the Guide to Clinical Preventive Services (U.S. Preventive Services Task Force) and the Guide to Community Preventive Services (Task Force on Community Preventive Services) provide examples of how expert opinion–used as the basis for some strategies and practices where scientific evidence of their effectiveness is not adequate–and empirical evidence can be reconciled.
Thus, the Framework can promote use of existing science and knowledge while concurrently fostering the development of new evidence of effective strategies and practices for continuous improvement.