Conceptualizing the Mechanisms of Social Determinants of Health: A Heuristic Framework to Inform Future Directions for Mitigation

Abstract

Policy Points A large body of scientific work examines the mechanisms through which social determinants of health (SDOH) shape health inequities. However, the nuances described in the literature are infrequently reflected in the applied frameworks that inform health policy and programming. We synthesize extant SDOH research into a heuristic framework that provides policymakers, practitioners, and researchers with a customizable template for conceptualizing and operationalizing key mechanisms that represent intervention opportunities for mitigating the impact of harmful SDOH. In light of scarce existing SDOH mitigation strategies, the framework addresses an important research-to-practice translation gap and missed opportunity for advancing health equity.

Context: The reduction of health inequities is a broad and interdisciplinary endeavor with implications for policy, research, and practice. Health inequities are most often understood as associated with the social determinants of health (SDOH). However, policy and programmatic frameworks for mitigation often rely on broad SDOH domains, without sufficient attention to the operating mechanisms, and effective SDOH mitigation strategies remain scarce. To expand the cadre of effective SDOH mitigation strategies, a practical, heuristic framework for policymakers, practitioners, and researchers is needed that serves as a roadmap for conceptualizing and targeting the key mechanisms of SDOH influence.

Methods: We conduct a critical review of the extant conceptual and empirical SDOH literature to identify unifying principles of SDOH mechanisms and to synthesize an integrated framework for conceptualizing such mechanisms.

Findings: We highlight eight unifying principles of SDOH mechanisms that emerge from landmark SDOH research. Building on these principles, we introduce and apply a conceptual model that synthesizes key SDOH mechanisms into one organizing, heuristic framework that provides policymakers, practitioners, and researchers with a customizable template for conceptualizing and operationalizing the key SDOH mechanisms that represent intervention opportunities to maximize potential impact for mitigating a given health inequity.

Conclusions: Our synthesis of the extant SDOH research into a heuristic framework addresses a scarcity of peer-reviewed organizing frameworks of SDOH mechanisms designed to inform practice. The framework represents a practical tool to facilitate the translation of scholarly SDOH work into evidence-based and targeted policy and programming. Such tools designed to close the research-to-practice translation gap for effective SDOH mitigation are sorely needed, given that health inequities in the United States and in many other parts of the world have widened over the past two decades.

Keywords: framework; health inequities; health policy; health programs; health system transformation; social determinants of health.

Figure 1

Eight Key Principles of Social Determinants of Health (SDOH) Mechanisms Shaping HIV Inequities. [Colour figure can be viewed at wileyonlinelibrary.com] Case examples for the application of the principles of SDOH mechanisms to HIV inequities. (A) SDOH act as underlying drivers of HIV transmission by shaping the distribution of HIV risk and protective factors., (B) SDOH influence manifests in the policy, economic, social, and physical dimensions of the HIV risk environment., (C) Adverse SDOH influences at the macro level (macro) are not deterministic in shaping HIV outcomes but interact with meso level (meso) and micro level (micro) influences. (D) SDOH influence in early life and over the life course shapes HIV treatment outcomes and disease progression., , (E) The impact of SDOH on HIV outcomes includes biological mechanisms of influence,, , , including inflammatory, , , , , , and neural, , , mechanisms. (F) SDOH shape HIV outcomes for several generations through three types of intergenerational influence., , , , , (G) SDOH shape the clustering of multiple cooccurring epidemics, which amplifies exposures and susceptibilities associated with increased HIV transmission., , (H) Social injustice shapes HIV inequities directly and in interaction with systematic differences in other SDOH., , , , ^. Abbreviations: CCR5, C‐C chemokine receptor type 5; CD4, cluster of differentiation 4; HPA, hypothalamic‐pituitary‐adrenal; IFG, inferior frontal gyrus; PrEP, HIV preexposure prophylaxis; STI, sexually transmitted infection; TPJ, temporo‐parietal junction.

Figure 2

The Center for Latino Adolescent and Family Health Framework of SDOH Mechanisms. [Colour figure can be viewed at wileyonlinelibrary.com] Abbreviations: macro, macro level; meso, meso level; micro, micro level; SDOH, social determinants of health.

Figure 3

Exemplar Application of the Framework for Operationalizing SDOH Mechanisms that Shape COVID‐19 Mortality Inequities in the South Bronx, New York City. We illustrate how the framework introduced in Figure 2 can be applied to a specific health inequity. Here, we show example operationalizations for each construct depicted in Figure 3 for an application to COVID‐19 mortality inequities in the South Bronx, New York City. In addition, we show the conceptualized causal relationships (arrows). Notably, a causal effect of exposure on susceptibility, as included in Figure 2, is not supported by theory or data for the current example and is therefore omitted, but inclusion of the relational form should be considered (based on theory, empirical data, and the published literature) when the framework is applied to a different health inequity. We emphasize that the family context should be recognized as important for shaping the depicted constructs and relational forms (e.g., past experiences with health services among family members are associated with an individual's trust in health care providers; health system literacy among parents can shape the receipt of health services for their children). The possibility of operationalizing framework constructs at multiple levels is illustrated here for resilience but can also be adopted for other constructs. Life‐course implications for COVID‐19 are not yet fully understood and are therefore not applicable for the current example, but the importance of a life‐course perspective for understanding the impact of SDOH on other health inequities is well established. Abbreviations: macro, macro level; meso, meso level; micro, micro level; SDOH, social determinants of health.