Social Determinants of Health (SDOH) Framework
Introduction
The Social Determinants of Health (SDOH) framework highlights the non‑medical conditions that influence health outcomes. According to the World Health Organization (WHO), SDOH are “the circumstances in which people are born, grow, live, work, and age, and the wider set of forces and systems shaping the conditions of daily life”. These determinants explain why health outcomes vary across populations and why inequities persist. Addressing SDOH is essential for achieving health equity and improving population health.
1. Definition and Importance
Definition: Non‑medical factors that affect health outcomes, including social, economic, and environmental conditions.
Importance:
Account for up to 50% of health outcomes.
Explain disparities across socioeconomic groups.
Provide actionable areas for policy and intervention.
2. Key Domains of SDOH (Healthy People 2030 Framework)
The U.S. Healthy People 2030 initiative identifies five domains:
Economic Stability – Employment, income, expenses, debt, medical bills.
Education Access and Quality – Literacy, language, early childhood education, vocational training.
Health Care Access and Quality – Insurance coverage, provider availability, cultural competence.
Neighborhood and Built Environment – Housing, transportation, safety, parks, walkability, pollution.
Social and Community Context – Social integration, support systems, discrimination, civic participation.
3. Structural vs. Intermediary Determinants
WHO distinguishes between:
Structural Determinants: Socioeconomic and political context (policies, governance, social stratification).
Intermediary Determinants: Material circumstances, psychosocial factors, behaviors, and biological processes.
4. Examples of SDOH in Practice
Economic Stability: Unemployment increases risk of poor nutrition and chronic illness.
Education: Higher literacy correlates with better health behaviors.
Healthcare Access: Lack of insurance leads to delayed treatment.
Neighborhood: Unsafe housing contributes to asthma and injury.
Social Context: Discrimination increases stress and mental health disorders.
5. Health Inequities and the Social Gradient
Social Gradient: Health outcomes improve with higher socioeconomic status.
Inequities: Differences are avoidable and unjust, driven by unequal distribution of resources.
Global Perspective: Low‑income countries face compounded inequities due to poverty, conflict, and weak infrastructure.
6. Policy and Intervention Strategies
Upstream Interventions: Address root causes (poverty reduction, education reform).
Midstream Interventions: Improve living conditions (housing, workplace safety).
Downstream Interventions: Provide direct care and health education.
Cross‑Sector Collaboration: Health systems must partner with education, housing, and labor sectors.
7. Role of Healthcare Professionals
Screen for SDOH during patient encounters.
Advocate for policies addressing inequities.
Collaborate with social workers and community organizations.
Educate patients about resources and support systems.
8. Measuring and Evaluating SDOH
Indicators: Employment rates, literacy levels, housing quality, access to care.
Tools: Community health assessments, surveys, electronic health record data.
Evaluation: Track progress toward equity goals (e.g., Healthy People 2030 objectives).
9. Challenges
Data collection inconsistencies.
Political resistance to redistributive policies.
Complexity of multi‑sector collaboration.
Cultural differences in defining health priorities.
10. Future Directions
Integration of SDOH data into electronic health records.
Expansion of value‑based care models that reward addressing SDOH.
Greater emphasis on global health equity through WHO and UN initiatives.
Use of AI and big data to identify at‑risk populations.
Conclusion
The SDOH framework underscores that health is shaped by far more than medical care. By addressing economic, educational, environmental, and social factors, societies can reduce inequities and improve overall well‑being. Nurses, physicians, policymakers, and communities all play critical roles in operationalizing this framework to achieve health equity.
Quiz: Social Determinants of Health (15 Questions)
Instructions
Select the best answer for each question. Each item is multiple choice.
1. Who defines SDOH as the conditions in which people are born, grow, live, work, and age? A. CDC B. WHO C. AMA D. NIH Answer: B
2. Which initiative identifies five domains of SDOH? A. WHO Global Health Report B. Healthy People 2030 C. CMS Medicare Guidelines D. UN Sustainable Goals Answer: B
3. Which domain includes employment and income? A. Education Access B. Economic Stability C. Social Context D. Neighborhood Environment Answer: B
4. Which domain includes literacy and language? A. Education Access and Quality B. Economic Stability C. Healthcare Access D. Social Context Answer: A
5. Which domain includes insurance coverage and provider availability? A. Education B. Healthcare Access and Quality C. Neighborhood Environment D. Social Context Answer: B
6. Which domain includes housing and pollution? A. Economic Stability B. Education C. Neighborhood and Built Environment D. Social Context Answer: C
7. Which domain includes discrimination and civic participation? A. Social and Community Context B. Economic Stability C. Education D. Healthcare Access Answer: A
8. What term describes the link between socioeconomic status and health outcomes? A. Health equity B. Social gradient C. Upstream intervention D. Downstream care Answer: B
9. Which determinants include policies and governance? A. Intermediary B. Structural C. Downstream D. Clinical Answer: B
10. Which determinants include material circumstances and behaviors? A. Structural B. Intermediary C. Policy D. Upstream Answer: B
11. Which intervention addresses root causes like poverty reduction? A. Upstream B. Midstream C. Downstream D. Clinical Answer: A
12. Which intervention improves living conditions like housing? A. Upstream B. Midstream C. Downstream D. Structural Answer: B
13. Which intervention provides direct care and education? A. Upstream B. Midstream C. Downstream D. Structural Answer: C
14. Which challenge involves political resistance? A. Data collection B. Policy implementation C. Cultural differences D. Collaboration Answer: B
15. Which future direction involves integrating SDOH into patient records? A. AI expansion B. Electronic health records C. Global health equity D. Value‑based care Answer: B
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