Frameworks to Address Social Determinants of Health

Both the U.S. and other countries recognize the importance of addressing social determinants of health (SDOH) as part of improving overall health and well-being. Several SDOH frameworks have been developed to help communities, health professionals, and others begin to better understand and address a variety of factors that affect health. This toolkit explores different aspects of SDOH — with a primary focus on the Healthy People 2030 and the World Health Organization (WHO) SDOH frameworks — and identifies promising approaches and evidence-based models to help rural organizations address SDOH to improve quality of life.

WHO Conceptual SDOH Framework

The WHO Conceptual SDOH framework demonstrates how social, economic, and political factors such as income, education, occupation, gender, race, and ethnicity influence a person's socioeconomic position which, in turn, plays a role in determining health outcomes. These factors can influence a person's ability to lead a healthy life, influencing things such as quality of housing, opportunities in the built environment that encourage physical activity, and access to healthcare services. In this framework, SDOH are categorized into two broad types that work together to impact health and well-being. These determinants are “structural determinants,” which include socioeconomic status and community/societal context, and “intermediary determinants,” which include the living and working conditions of people.

Healthy People

Healthy People is an initiative that sets national objectives each decade to help monitor and improve the health of the U.S. The initiative aims to identify key areas important for improving health, and to develop objectives that communities can use to measure progress towards achieving health goals. For Healthy People 2030, a continuation of the Healthy People initiative that set nationwide health objectives for 2010 through 2030, a framework was developed that organized SDOH into five areas. Using these five key areas, this toolkit looks at evidence-based and promising approaches rural programs can use to address SDOH in communities. These domains are programs that address changes to:

1. Economic stability
2. Education access and quality
3. Social and community context
4. Healthcare access and quality
5. Neighborhood and built environment

Within each of these domains, Healthy People 2030 outlines important SDOH. For example, within the domain of economic stability are factors such as employment, food insecurity, housing instability, and poverty.

Ecological Models

Ecological perspectives of SDOH acknowledge the interaction of several levels of individual, interpersonal, institutional, policy, and structural factors that affect health and well-being. One rural adaptation of an ecological model in an African American community categorizes SDOH into five areas: individual traits and behaviors, relationships and social support, built environment, laws and policies, and “superstructural” social issues such as racism and sexism.

Another ecological framework adopted by the California Department of Public Health recognizes the complex interactions between many factors that were previously not considered to impact health outcomes, with a particular focus on improving health equity. Different communities and programs have also adopted the Social-Ecological Model as a framework to address social determinants of health. This approach looks at addressing different levels of social and structural factors that influence health and well-being.

Rural Community Health & Well-Being Framework

Canadian researchers from the Rural Development Institute have also developed a rural-specific framework to describe SDOH and factors that make up healthy communities. The Rural Community Health and Well-Being Framework identifies social, economic and environmental factors as key drivers of health in rural communities, but adds ten additional categories that rural residents have highlighted as important factors in determining health and well-being. These additional categories include:

• Health
• Safety and security
• Economics
• Education
• Environment
• Community infrastructure
• Recreation/heritage and arts
• Community processes
• Social supports
• Population

Resources to Learn More

A Conceptual Framework for Action on the Social Determinants of Health: Social Determinants of Health Discussion Paper 2
Document
Describes how the conceptual framework for understanding the SDOH was developed by the Commission on Social Determinants of Health. Identifies the elements of policy action and policy implications for addressing SDOH.
Author(s): Solar, O. & Irwin, A.
Organization(s): World Health Organization
Date: 2010

A Framework for Educating Health Professionals to Address the Social Determinants of Health
Document
Outlines a framework for teaching health professionals during their initial training and through professional development on how to address SDOH.
Organization(s): Institute of Medicine, National Academies of Sciences, Engineering, and Medicine
Date: 2016

Michael Marmot and the Social Determinants of Health
Video/Multimedia
An interview with Michael Marmot from University College London discussing several key concepts related to SDOH and health equity.
Organization(s): American Public Health Association
Date: 11/2016

Partnering to Catalyze Comprehensive Community Wellness: An Actionable Framework for Health Care and Public Health Collaboration
Document
Describes a shared vision and framework for collaboration and coordination between public health and healthcare sectors working together to improve U.S. health and well-being.
Organization(s): Health Care Transformation Task Force, the Public Health Leadership Forum
Date: 6/2018