An Introduction to Health Risk and Enabling Factors Framework

Dynamics driving health and well-being are complex. In the field of public health and more broadly among those working to advance equitable well-being, frameworks—a basic structure underlying a system, concept, or text—are a powerful tool that aid in understanding and sense-making. Frameworks provide conceptual infrastructure and help us understand the complex nature of health and well-being. “Framing” is a way of structuring or presenting a problem or an issue; it involves explaining, describing, and adding context.

A framework provides a holistic view and approach to community change work, and prompts users to consider relevant upstream factors they might not otherwise. Importantly, frameworks are not mutually exclusive—in fact, using multiple frameworks offers a way to explore an issue from different perspectives.

Frameworks can be applied to quantitative data to help us more-effectively use data to inform our work. Data frameworks are arranged into a simple series of “domains” (or categories) that categorize a set of indicators that measure community health and well-being. Learn more about data frameworks and how they can be leveraged to improve community health and well-being.

What is the Health Risk and Enabling Factors Framework?

The Health Risk and Enabling Factors (HREF) Framework identifies behaviors and conditions that contribute to both positive and negative health outcomes. It provides a comprehensive view of factors that impact disease burden in a community and offers insights into areas where interventions can be most effective.

The framework is structured around two core components:

Health Risks: Behaviors and conditions that elevate the likelihood of poor health outcomes, such as smoking, physical inactivity, and substance abuse.

Health Enabling Factors: Conditions that support healthy behaviors, such as access to preventive care, food security, and safe environments.

The HREF Framework is designed to work alongside other health frameworks, like the Burden of Disease (BoD) framework, to allow practitioners to target modifiable health-related behaviors. By focusing on these behaviors, the framework aims to reduce risk of chronic disease, mortality, disability, and diminished quality of life.

HREF Framework Domains

Chronic Disease Management:

Measures chronic disease patient adherence to treatments that can improve quality of life and reduce healthcare costs. Indicators include medication adherence for patients with high blood pressure and high cholesterol, and receipt of care for patients with HIV. Adherence to prescribed medications and treatment schedules is critical for long-term success of patients living with chronic diseases.

Diet and Exercise:

Measures healthy eating behaviors, physical activity levels, food access and security, and lifestyle-related diseases. Indicators include physical activity rates, healthy eating rates, diet-related diseases, and food security and access. Eating healthfully and being active reduce risk of chronic disease and are associated with good overall health.

Accident and Injury Prevention:

Measures behaviors that impact risk for accidents and injuries that result in poor health outcomes. Indicators include sleep, traffic safety measures, employment in accident-prone occupations, and firearm safety. Safety measures and behaviors that reduce risk for accidents and injuries prevent morbidity, mortality, and disability.

Preventive Care:

Measures the utilization of preventive health services and associated factors that impact uptake. Indicators include use of primary care, disease screenings, vaccinations, and health care access. Routine, preventive health services facilitate early detection of disease and prevent illnesses.

Risky Sexual Behavior:

Measures sexual behaviors that impact risk for sexually transmitted infections and unintended pregnancies. Indicators include condom use, early sexual intercourse, and STI outbreaks. Risky sexual behavior can lead to infections including chlamydia, syphilis, and HIV, as well as unintended pregnancy.

Tobacco, Alcohol and Substance Use:

Measures tobacco, alcohol, and substance use behaviors, and factors that impact substance use. Indicators include history of cigarette smoking, problem drinking, drug use, secondhand smoke exposure, and access to controlled substances. Use of tobacco, alcohol, and substances is associated with acute and chronic diseases, including cancers, cardiovascular diseases, mental illness, and more.

Importance of the HREF Framework

Understanding factors influencing health outcomes is crucial for promoting long-term well-being. This framework helps target specific behaviors (and related conditions) that increase risk, and to identify enabling factors that foster better health. By addressing both health risks and enabling factors, the HREF Framework shifts public health interventions toward holistic approaches that reduce negative behaviors and create healthier environments.

History of the HREF Framework

Health risks such as tobacco use, unhealthy diet, and substance abuse disproportionately affect low-income and marginalized communities. These behaviors have been linked to higher rates of chronic diseases, disability, and premature death. Understanding the connection between health risks, enabling factors, and disease burden is essential to implementing strategies that create conditions to break the cycle of health inequities.

The HREF framework was developed by the IP3 team and leverages administrative data from sources like PLACES, American Community Survey, County Health Rankings, Mapping Medicare Disparities Tool, Map the Meal Gap, USDA Food Access Research Atlas, BMJ Open, CDC AtlasPlus, National Environmental Public Health Tracking Network, Medicare Part D Opioid Prescribing Tool, County Business Patterns, Small Area Estimates for Cancer-Related Measures, and Bureau of Economic Analysis.

Equity Considerations

When using any data framework, it is important to take into account what the data can and cannot tell us about health disparities. Health disparities disproportionately affect marginalized communities and behaviors such as tobacco use, poor diet, and inadequate chronic disease management can exacerbate these inequities. When looking at change over time for an indicator, it’s helpful to explore change overall and dig in to see whether changes are different for specific population groups.

Opportunities for Local-Level and Systemic Use of the HREF Framework

At the local level, public health practitioners can use this framework to:

• Inform health promotion programs by identifying key behaviors to target
• Conduct health assessments to better-understand community needs
• Design interventions that reduce health risks while promoting enabling factors

Systemic Use

At the systemic level, the framework can be used to:

• Advocate for policy changes that expand access to preventive care and healthier environments
• Promote safer environments to reduce injury and risk behaviors
• Increase funding for chronic disease management programs