There’s growing awareness that factors like housing, income, education, and social environments, collectively known as Social Determinants of Health (SDoH), play a significant role in shaping the overall health of individuals and communities. For public and behavioral health organizations, incorporating SDoH data into health strategies is essential to improving equity and outcomes.
What Are Social Determinants of Health?
Social Determinants of Health are the social, economic, and environmental conditions that influence a person’s health. These include where people live, work, learn, and play—affecting everything from access to nutritious food and safe housing to exposure to violence and environmental hazards. When health care providers and public health agencies understand these determinants, they can better identify at-risk populations and design more effective interventions.
When evaluating public health strategies, it's important to consider all important aspects of health—including physical, mental, emotional, and social well-being. Social environments, community safety, and economic stability are as crucial as clinical care in determining a population's health outcomes. Ignoring these components limits the effectiveness of even the most advanced healthcare systems.
Health Care Access and Quality
Among the core SDoH categories is health care access and quality, which refers to an individual's ability to receive timely, affordable, and appropriate health care services. Poor access due to transportation issues, lack of insurance, or provider shortages leads to delayed care, unmanaged chronic conditions, and avoidable hospitalizations. Public health systems must track this determinant closely to improve outreach and reduce disparities.
The Role of SDoH in Mental Health
Social determinants of mental health, like housing instability, food insecurity, and unemployment, contribute significantly to the onset and persistence of mental health conditions. Individuals living in unsafe or isolated environments may have limited access to supportive resources, increasing the risk of anxiety, depression, and substance use disorders. Integrating mental health SDoH data into public health systems allows for more holistic care planning and prevention.
Structural and Intermediary Determinants of Health
The World Health Organization breaks SDoH into two categories: structural and intermediary determinants of health.
Structural Determinants of Health
Structural determinants of health include the broader political, economic, and social systems that create health inequity. These encompass laws, policies, governance, and socioeconomic status—all of which shape how resources are distributed. For instance, systemic racism and discriminatory housing practices can limit access to healthy environments for specific populations, worsening long-term health outcomes.
Intermediary Determinants of Health
Intermediary determinants are the day-to-day conditions people face that directly impact their health. These include living conditions, employment status, income, and psychosocial stressors. Structural determinants often shape these factors but represent people's more immediate challenges. Public health departments must understand both levels to design effective, equity-focused programs.
Addressing SDOH Through Integrated Care Models
To effectively address SDoH in the United States, many public health agencies are adopting integrated care models that combine physical health, mental health, and social services. These models help eliminate silos, making care delivery more efficient and responsive to social needs.
The Social Ecological Model
The social ecological model provides a multi-level approach to understanding how SDoH interact. It emphasizes that health behaviors and outcomes are shaped by multiple levels of influence—individual, interpersonal, community, institutional, and policy. Health programs that address each of these levels are more effective at creating lasting change.
Integrated Behavioral Health
IBH stands for Integrated Behavioral Health, a model that merges mental health services into physical care settings, specifically for those with Medicaid. For individuals experiencing mental health illness, they can receive outpatient mental health or SUD services at their public or primary care clinic.
IBH ensures timely mental health support, often the missing piece in holistic care. Public health departments incorporating IBH can more effectively address the emotional impacts of social stressors like poverty, trauma, and isolation.
Collaborative Care Model
The Collaborative Care Model is another approach to care that integrates physical and behavioral health services, making it especially effective in addressing Social Determinants of Health. This model ensures that patients' medical, mental, and social needs are treated holistically by bringing together primary care providers, behavioral health specialists, and care managers.
Care managers often play a key role in identifying SDoH challenges and coordinating referrals to community resources. This integrated framework allows for more personalized, equitable care that targets the root causes of poor health outcomes.
Using SDoH Data Through Technology
Collecting and using Social Determinants of Health (SDoH) data is essential for improving health outcomes and advancing health equity. Technology is crucial in helping healthcare organizations understand and respond to the non-medical factors affecting individuals' health. From identifying risk factors to coordinating services, digital tools enable more personalized, informed, and proactive care.
Here are some key tools that support the collection and application of SDoH data:
- EHR-integrated SDoH screening forms – Customizable intake and assessment tools embedded in electronic health record systems to collect housing, food security, education, and income data.
- Data dashboards and visual analytics – Visualization of trends in social risk factors across populations to support data-driven decision-making.
- Referral Orders – Systems that allow providers and care teams to connect individuals to social services and track whether those referrals lead to successful outcomes.
- Telehealth platforms – Virtual care tools that improve access to healthcare and social support, especially for individuals facing transportation, mobility, or geographic barriers.
- Mobile health and community outreach tools – Solutions that support remote screening, education, and follow-up outside traditional care settings.
Person-Centered Approaches to Social Health
A truly effective response to Social Determinants of Health begins with understanding the whole person, not just their medical conditions, but the social, economic, and environmental factors influencing them. A person-centered approach, or whole-person care, ensures that care is tailored to an individual’s unique circumstances, values, and lived experiences. This means asking what health issues exist, why they persist, and what barriers might hinder better health.
Whole person care allows organizations to improve health equity by confronting the underlying causes of poor health—paving the way for more equitable, sustainable outcomes.
When patients actively participate in their care and their social context is fully considered, outcomes improve. Technology plays a key role in supporting these efforts. EHR systems that enable care coordination, referrals to social services, and tracking of social needs help healthcare providers and community organizations embed person-centered principles into daily workflows.
Social determinants of health (SDoH) are foundational to healthcare. From determinants like education to intermediary determinants like income and housing, these factors shape health at every level. Collecting and acting on SDoH data through technology, implementing integrated care models, and embracing person-centered approaches are all essential strategies for addressing disparities and improving health equity.
