Leader and organizational stakeholder perspectives on healthcare responsibility for addressing Social and Digital Determinants of Health (SD-DOH) in the United States: a scoping review and qualitative evidence synthesis

Abstract

Background

U.S. health systems are increasingly expected to address social and digital determinants of health (SD-DOH) as part of equity-oriented transformation. While prior research documents growth in equity-oriented initiatives, less is known about how leaders and stakeholders frame healthcare organizations’ responsibilities for this work, and whether those responsibility perspectives align with observed equity-oriented action. To address this gap, this study integrates two complementary conceptual lenses: (1) four strategic levers used by health systems to address SD-DOH: enabling services (downstream), community partnerships (midstream), policy advocacy (upstream), and direct community investment (upstream); and (2) responsibility perspectives grounded in the National Academy of Medicine’s (NAM) 5 A Social Care Framework (Awareness, Assistance, Adjustment, Alignment, Advocacy), extended by this study to include a sixth domain, system governance and accountability.

Methods

We conducted a PRISMA-ScR–guided scoping review with qualitative evidence synthesis of U.S.-based peer-reviewed and gray literature published between January 2020 and June 2025. Four databases (PubMed, Scopus, ProQuest, CINAHL) were searched to identify empirical and conceptual sources reflecting leader or stakeholder perspectives on SD-DOH (N = 94). Descriptive synthesis characterized initiatives; reflexive thematic analysis examined responsibility perspectives and strategic levers, while alignment between them was assessed using cross-tabulations.

Results

Equity-oriented action was concentrated in enabling services (86%) and community partnerships (70%), while policy advocacy (34%) and direct community investment (9%) were less common. Responsibility perspectives were multi-dimensional, with Alignment (83%) most prevalent, followed by Assistance (68%), Adjustment (65%), Awareness (61%), and system governance & accountability (60%); Advocacy appeared least often (32%). Alignment patterns were strong: 100% of community partnerships and 100% of direct community investment initiatives reflected Alignment (and so did 83% of enabling service initiatives). Assistance and Adjustment were tightly coupled with enabling services (98% each). By contrast, Advocacy was concentrated in upstream action: 88% of direct community investment initiatives (vs. 25% of enabling services initiatives). System governance & accountability functioned as a bridge across levers, appearing in 100% of direct community investment initiatives, 75% of policy advocacy initiatives, 56% of community partnerships and 54% of enabling service initiatives.

Conclusions

Responsibility framing consistently aligned with equity-oriented action across U.S. health systems. While upstream strategies remain limited, the widespread presence of system governance and accountability suggests the field may be at an inflection point. Institutionalizing responsibility for equity through governance, measurement, partnerships, and shared accountability may be essential for more sustained upstream engagement, with policy advocacy representing a feasible near-term pathway for systems with foundational alignment capacity.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12889-026-29142-x.

Introduction

Health systems in the United States increasingly recognize that social determinants of health shape whole-person care, health equity, and population-level outcomes [1, 2]. Social conditions such as housing stability, food security, transportation access, education, and employment have long been linked to preventable illness and unequal access to care, prompting growing attention to how healthcare organizations can address social barriers alongside clinical needs [3, 4].

This shift has been reinforced by national efforts to advance the Quintuple Aim, widely used U.S. healthcare effectiveness framework that builds on the Triple Aim by adding provider wellbeing and health equity as core dimensions alongside patient experience, cost, and population health, positioning equity as a central component of system performance [5]. Value-based payment models, population health initiatives, and related policy efforts have further underscored the role of social conditions in influencing clinical outcomes and costs [1, 6]. Together, these developments have encouraged healthcare organizations to reconsider traditional boundaries of responsibility and to explore strategies that address social barriers to care as part of equity-centered transformation [7].

At the same time, rapid digital transformation has expanded the conditions that shape access to care. Broadband availability, device access, and digital literacy now influence participation in telehealth, patient portals, remote monitoring, and other digital tools central to care delivery in today’s environment [8]. Digital factors can both mitigate and exacerbate health inequities: while digital tools such as smartphones and telehealth platforms can enhance access to care for populations facing traditional barriers (e.g., transportation), digitally enabled care may preferentially benefit individuals who are already well connected to the healthcare system, while disadvantaging those with limited digital access, literacy, or technological resources, thereby reinforcing existing inequities and creating overlapping challenges for populations with constrained resources [9–11]. As digital tools increasingly define how care is delivered and experienced, digital equity and inclusion have become integral to achieving equitable, high-quality care. Current national health information technology priorities, including those advanced under the 21st Century Cures Act, a U.S. federal law enacted in 2016 to accelerate medical innovation and expand health data access and interoperability, reflect growing recognition that equity-centered health systems must address both social and digital conditions [9, 12].

In this manuscript, we use the term social and digital determinants of health (SD-DOH) to capture this interconnected set of conditions shaping individuals’ ability to access, navigate, and benefit from care. SD-DOH reflects the reality that social and digital factors operate jointly in practice, influencing opportunities for engagement and wellbeing. Policy mechanisms such as Community Health Needs Assessments (CHNAs) and the Centers for Medicare & Medicaid Services (CMS) Framework for Health Equity further reinforce expectations that healthcare organizations address both social and digital determinants [7]. Together, these developments signal an expanded conception of health system responsibility.

Despite this growing policy attention, health systems continue to grapple with how to balance downstream and upstream approaches to SD-DOH. Downstream activities, such as screening, referrals, and enabling services, can address immediate needs but often remain fragmented or short-term [13]. Upstream strategies, by contrast, require longer-term investments, community-aligned partnerships, supportive policies, and attention to structural conditions shaping health [14]. These distinctions raise fundamental questions about how health system leaders frame organizational responsibility for SD-DOH and how such interpretations shape priorities, investments, and equity-oriented action.

Literature synthesis and research gap

A growing body of work documents expanded U.S. health system engagement with social determinants of health, driven by community benefit expectations, value-based payment, and federal initiatives encouraging social care integration [15]. Common areas of action include housing instability, food insecurity, and related social conditions shaping access, outcomes, and equity. Yet across reviews and empirical studies, efforts to address social and digital determinants are often described as fragmented and uneven, with a strong concentration in downstream approaches such as screening, referrals, and short-term enabling supports, rather than sustained strategies that alter underlying community conditions [16]. These downstream approaches can address immediate barriers, but they often rely on time-limited funding, remain weakly embedded in clinical workflows and data systems, and are difficult to scale or sustain [13].

A parallel stream of literature cautions that fragmented social care programs may have limited equity impact and can unintentionally reproduce or amplify inequities when they prioritize easily reached subgroups, treat social needs as individual deficits, or operate without clear accountability or cross-sector coordination [1, 5, 15]. These concerns have increased attention to governance, shared accountability, and the organizational infrastructure needed to translate social care activities into durable equity gains [17]. The literature also shows that digital determinants have often been under-integrated into health system SD-DOH strategies, even as broadband, device access, and digital literacy increasingly shape equitable participation in care [18–20]. Taken together, this evidence highlights a continuing tension between downstream efforts that respond to individual needs and upstream strategies that address the policies, systems, and structural conditions that create inequities [16, 21].

Prior systematic reviews have also identified four strategic levers, through which health systems engage in equity-oriented SD-DOH work: enabling services, community partnerships, policy advocacy, and direct community investment [1, 16, 21]. These reviews consistently found that while screening and short-term supports were common, fewer organizations pursued sustained upstream strategies such as cross-sector alignment, policy advocacy, or long-term community investment. More recent work on digital health equity within Learning Health Systems similarly highlights organizational conditions that support digital inclusion, including shared values, organizational learning, and integration of social and digital strategies [16, 17]. Together, this literature suggests that how leaders and organizational stakeholders view responsibility for SD-DOH shapes whether organizations pursue fragmented activities or sustained transformation.

Within this broader context, national frameworks provide guidance on how health systems might frame their roles and responsibilities in addressing SD-DOH and how this framing may relate to action. The National Academy of Medicine’s (NAM) 5 A Social Care Framework delineates five domains of activity, Awareness, Assistance, Adjustment, Alignment, and Advocacy, distinguishing between activities focused on responding to individual social needs and those aimed at coordinating across sectors and influencing broader social and structural conditions [22]. Complementary perspectives, including the Robert Wood Johnson Foundation’s Culture of Health and implementation frameworks such as Consolidated Framework for Implementation Research (CFIR), further highlight shared values, leadership engagement, governance capacity, and organizational readiness as important conditions for sustained equity-oriented work [23, 24].

Understanding how leaders and organizational stakeholders interpret health system responsibility for SD-DOH is therefore central to understanding equity-oriented transformation [25]. These responsibility perspectives can shape whether organizations pursue fragmented, compliance-driven activities or more integrated strategies that align downstream services, community partnerships, and upstream efforts around shared equity goals [15]. In this context, compliance-driven activities often reflect responses to external policy requirements, such as CMS initiatives related to social risk screening, quality reporting, and value-based care models, which may incentivize documentation and short-term interventions rather than sustained, system-level equity strategies. Responsibility framing can also influence whether digital inclusion is treated as peripheral or as foundational to equitable care delivery [26]. At the same time, these perspectives are shaped within broader organizational and external contexts, including market conditions, policy environments, and funding priorities, which may enable or constrain how responsibility is translated into strategy and action.

Yet empirical insights into how responsibility perspectives align with observed equity strategies across organizational contexts, remain dispersed across qualitative and mixed-methods studies, policy analyses, and commentaries, limiting theoretical understanding of how responsibility framing translates into action across organizational contexts. This represents a critical gap in the literature.

Study purpose and significance

The purpose of this study is to synthesize how leaders and organizational stakeholders in U.S. health systems frame organizational responsibility for addressing SD-DOH, and to examine how these responsibility perspectives align with observed equity-oriented action. By integrating diverse empirical and conceptual sources, this scoping review assesses alignment between responsibility framing and strategic approaches across downstream, midstream, and upstream initiatives, and examines how these patterns vary by organizational context. Grounded in national frameworks for social care integration and equity readiness, this scoping review advances theory on health system responsibility by clarifying how responsibility framing corresponds with action and readiness for equity-centered transformation.

Research questions

Guided by these aims, this review was shaped by five research questions:

• RQ1. What types of equity-oriented initiatives are being implemented within U.S. health systems, and how do these initiatives vary by strategic lever, implementation stage, outcome orientation, and SD-DOH domains?

• RQ2. How do health system leaders and organizational stakeholders frame healthcare organizations’ responsibilities for addressing social and digital determinants of health?

• RQ3. To what extent do leaders’ and organizational stakeholders’ responsibility perspectives align with observed equity strategies, including downstream, midstream, and upstream approaches?

• RQ4. How do responsibility perspectives vary across organizational types?

• RQ5. What do leader and organizational stakeholder perspectives, together with identified facilitators, barriers, and accountability structures, reveal about health systems’ readiness and strategic capacity to advance equity-oriented work?

Conceptual framework

The research questions examine two interrelated dimensions of equity-oriented transformation in U.S. health systems: (1) the equity-oriented initiatives undertaken to address social and digital determinants of health (SD-DOH), and (2) how leaders and organizational stakeholders frame healthcare organizations’ responsibilities for addressing SD-DOH. Bringing these dimensions together moves the review beyond describing programs toward explaining how responsibility framing, readiness, and strategic capacity shape equity-oriented action across settings.

This study integrates two complementary lenses. The first is a strategic levers lens, used to characterize how health systems act on SD-DOH through enabling services, community partnerships, policy advocacy, and direct community investment. The second is a responsibility perspectives lens, grounded in the NAM 5 A framework and extended in this study to include a sixth domain, system governance and accountability, to address a key implementation gap and capture the governance and accountability mechanisms and organizational structures and processes needed to sustain equity-oriented work in a durable and institutionalized manner. This added domain is conceptualized as a cross-cutting organizational capacity that enables system-level responsibilities to be operationalized and sustained in practice, linking responsibility framing with the organizational capacity required for implementation.

Figure 1 presents the integrated conceptual framework guiding this study, illustrating how responsibility perspectives relate to and shape equity-oriented action across downstream, midstream, and upstream strategies, and providing the analytic foundation for examining alignment between what health systems do and how responsibility is framed.

Fig. 1.

Integrated conceptual framework. This figure presents the integrated conceptual framework linking responsibility perspectives with observed equity-oriented action across strategic levers. The framework illustrates how responsibility framing aligns with downstream, midstream, and upstream strategies and incorporates an extended responsibility domain, system governance and accountability, to capture organizational structures that support sustained equity-oriented action

SD-DOH strategic levers as a lens for characterizing equity-oriented initiatives

To characterize what health systems do, this study draws on prior work identifying four strategic levers through which healthcare organizations engage SD-DOH: enabling services, community partnerships, policy advocacy, and direct community investment [16, 27]. These levers provide an analytic lens for distinguishing how health systems distribute effort across downstream, midstream, and upstream approaches, while acknowledging that initiatives often combine multiple levers.

Enabling services reflect downstream-oriented activities intended to identify needs and reduce barriers to care, including screening, navigation, referrals, care coordination, and wraparound supports. Community partnerships represent a more relational and operationally integrated mode of engagement, extending beyond transactional referrals to include sustained collaboration with community-based organizations (CBOs), shared workflows, and co-designed processes. Policy advocacy reflects efforts to influence financing, regulation, and governance environments that shape social and digital conditions. Direct community investment represents the most upstream lever and includes financial, or capacity-building investments intended to shift community conditions over time [1, 28, 29].

The four levers are not mutually exclusive; initiatives often combine them. In this study, the strategic levers lens provides the primary foundation for analyzing initiative characteristics (RQ1) and assessing alignment between responsibility perspectives and observed equity-oriented action (RQ3). By situating initiatives along these levers, the framework allows assessment of whether health systems remain concentrated in downstream efforts or demonstrate movement toward more upstream, community-aligned action.

NAM 5A and system governance and accountability as a lens for responsibility perspectives

Strategic levers classify action but do not explain how leaders and organizational stakeholders frame organizational responsibility for SD-DOH. To examine this dimension, the framework draws on the National Academy of Medicine’s (NAM) 5 A Social Care Framework, which outlines five domains of social care integration: Awareness, Assistance, Adjustment, Alignment, and Advocacy [22]. The framework distinguishes between activities focused on identifying and responding to individual social needs and activities aimed at coordinating across sectors and influencing broader social and structural conditions. Because NAM 5 A provides an established vocabulary for the scope of health system engagement in social care, it offers a useful foundation for interpreting how responsibility for SD-DOH is framed and whether those framings emphasize individual-level support, system-level coordination, and/or structural change.

At the same time, an important implementation gap remains in how system-level responsibilities are operationalized in practice. While NAM 5 A delineates domains of action, it provides limited guidance on how healthcare organizations develop the internal capacity, governance structures, measurement systems, and accountability mechanisms needed to sustain Alignment and Advocacy. As a result, health systems may endorse system-level responsibilities in principle while remaining constrained in what they can reliably execute, scale, or institutionalize. Prior work in implementation science and health systems transformation similarly emphasizes that leadership engagement, organizational readiness, governance capacity, and continuous learning are critical conditions for sustained equity-oriented work [17, 30].

To address this gap, this study extends the NAM 5 A framework by introducing a sixth, cross-cutting domain: system governance and accountability. This domain captures the organizational infrastructure required to embed equity priorities into leadership decision-making, operational workflows, data and measurement systems, and cross-sector coordination, and to hold organizations accountable for equity-oriented outcomes. Rather than replacing existing domains, this addition provides a mechanism through which Alignment and Advocacy can move from aspirational commitments to sustained and institutionalized practice. Conceptually, it also serves as a bridge between responsibility framing and observed action by identifying the structures through which responsibility is enacted in practice.

Within this study, responsibility perspectives are therefore treated as multi-dimensional. In addition to the NAM 5 A domains and the added system governance and accountability domain, responsibility is examined in terms of how leaders and organizational stakeholders explain and justify responsibility in practice and how those framings are linked to concrete actions and behaviors. Detailed operationalization of these constructs, including data elements, analytic mapping, and thematic coding procedures, is provided in Appendix 1 (Data Elements and Analytic Mapping) and Appendix 2 (Analytic Codebook and Thematic Analysis Framework), which further detail the structured classification of strategic levers and the multi-dimensional coding of responsibility perspectives.

Methodology

This study is guided by the integrated conceptual framework described in the Introduction and depicted in Fig. 1. Guided by this framework and the five research questions, we conducted a scoping review with qualitative evidence synthesis to examine how leaders and organizational stakeholders in U.S. health systems frame responsibility for social and digital determinants of health (SD-DOH), and how these perspectives align with observed equity-oriented initiatives. Scoping review methodology was selected to accommodate a methodologically diverse body of empirical, conceptual, and policy-oriented literature and to enable synthesis of responsibility perspectives across heterogeneous sources.

This review was conducted in accordance with PRISMA-ScR guidance [31]. The analytic focus was on identifying cross-study patterns in responsibility framing, equity action, and organizational readiness, rather than evaluating intervention effectiveness or causal impact. A detailed review protocol is provided in Appendix 3; the protocol was not registered. Adherence to PRISMA-ScR reporting standards is documented through the checklist in Appendix 4.

Information sources

Four academic databases were searched to identify eligible literature: PubMed, Scopus, ProQuest, and CINAHL. These databases were selected to capture interdisciplinary evidence spanning healthcare delivery, public health, management, social services, digital health, and equity-oriented research. Searches covered publications from January 1, 2020, through June 30, 2025, and were conducted in July 2025. All publication types available in English were eligible for inclusion. Although no separate gray literature search was conducted, ProQuest indexes dissertations, trade publications, and other gray literature in addition to peer-reviewed articles.

Search strategy

Search terms were organized into four concept groups aligned with the conceptual framework: (1) healthcare organizational settings (e.g., hospitals, health systems, primary care organizations, community health centers, community-based organizations); (2) leadership and administrative roles (e.g., leaders, executives, administrators, managers, and related controlled vocabulary terms); (3) social and digital determinants of health (e.g., social determinants of health, digital inclusion, digital health equity, health information technology); and (4) perception- and perspective-oriented terms (e.g., perspectives, experiences, narratives, views). Boolean operators were used to ensure retrieved records reflected organizational context, SD-DOH content, and articulated viewpoints. Search strings were adapted for each database to align with indexing conventions. The complete search strategy used on all four databases is provided in Appendix 5.

Eligibility criteria

Eligibility was determined based on conceptual relevance to the five research questions. Sources were included if they: (1) focused on the United States; (2) were published in English between January 1, 2020, and June 30, 2025; (3) were empirical or conceptual in nature, including qualitative, mixed-methods, quantitative, policy, commentary, review, protocol, or dissertation sources; and (4) contained interpretive statements reflecting leader or organizational stakeholder perspectives on health system responsibility, governance, strategy, or decision-making related to social and/or digital determinants of health.

Sources were excluded if they were conducted outside the United States, if full text could not be retrieved after multiple attempts, or if they fell outside the analytic scope of the review. Excluded studies primarily focused on patient-only outcomes, technical implementation details without organizational interpretation, training-only interventions, digital usability studies without equity relevance, or SD-DOH workflows without leader or organizational stakeholder perspectives.

Process for selecting sources of evidence

Study selection followed a three-stage screening process. After database search and de-duplication, 3,615 records proceeded to title and abstract screening, during which clearly ineligible sources were excluded. A total of 296 records advanced to full-text review, where eligibility was assessed in detail. Following full-text screening, 94 articles met all inclusion criteria and were retained for synthesis [1, 2, 4, 7, 8, 12–15, 25, 26, 32–114]. Screening and eligibility assessment were conducted by four reviewers, with ambiguous cases resolved through regular discussion and consensus. A PRISMA-ScR flow diagram summarizing the selection process is presented in Fig. 2.

Fig. 2.

PRISMA flow chart for article selection. This figure presents the PRISMA Extension for Scoping Reviews (PRISMA-ScR) flow diagram outlining the process of study identification, screening, eligibility assessment, and inclusion. The diagram summarizes the number of records identified through database and supplementary sources, screened, excluded, and included in the final synthesis

Consistent with the purpose of the review, no formal (methodological) critical appraisal was conducted. This decision reflects the study’s focus on synthesizing how responsibility is framed across a deliberately inclusive evidence base rather than assessing intervention effectiveness. Such an approach is aligned with scoping review methodology when the analytic goal is conceptual integration rather than causal inference [31].

Process for data charting and thematic coding

Data charting and analysis proceeded in two analytically complementary phases, enabling both systematic characterization of equity-oriented initiatives and interpretive synthesis of responsibility perspectives.

Phase 1: structured data charting of descriptive and deductive variables

In the first phase, four researchers independently extracted descriptive and largely deductive variables directly from the full texts of included articles using a structured charting template aligned with the conceptual framework and research questions. Charted variables included study design, geographic scope, population focus, funding mechanisms, organizational type, stakeholder group, leadership level, SD-DOH domains addressed, equity depth, implementation stage, and outcome orientation. A detailed description of all charted variables and their mapping to the research questions is provided in Appendix 1.

Regular team meetings were used to review ambiguous cases, refine category definitions, and ensure consistent application of charting rules across reviewers. Discrepancies were resolved through discussion and consensus. This phase produced a consolidated descriptive dataset that served as the empirical foundation for summary tables and contextualized interpretation of analytic patterns in the Results.

Several variables across both descriptive and interpretive constructs in the dataset, were coded as non-mutually exclusive. Individual studies frequently addressed multiple population groups, involved multiple organizational types, employed more than one strategic lever, and reflected multiple responsibility domains. Accordingly, analyses rely on co-occurrence across studies rather than assignment to a single dominant category. Counts therefore reflect the number of studies in which a given variable is present, and percentages may exceed 100% by design. This approach aligns with the study’s systems-oriented perspective and allows for more accurate representation of how equity-oriented strategies and responsibility perspectives are articulated across complex organizational contexts.

Phase 2: thematic coding of qualitative constructs

In the second phase, constructs requiring interpretive judgment, beyond structured descriptive data charting, were analyzed using reflexive thematic analysis following Braun and Clarke’s six-phase approach [115]. This phase was led by two members of the research team (PR and AT) and was conducted over an approximately three-month period following completion of data charting. The focus of this phase was on examining how responsibility for SD-DOH was described, how these descriptions were linked to specific equity-oriented actions, and how organizational conditions such as facilitators, barriers, and accountability structures were represented in the text. PR is an experienced health services researcher, and AT is a collaborative researcher with prior co-authored work in public health and health systems research, supporting a shared understanding of the topic while bringing complementary perspectives to the analysis. Reflexivity was maintained through ongoing discussion and critical reflection to ensure that interpretations remained grounded in the data rather than individual subjectivity.

PR and AT worked closely together throughout this process, beginning with in-depth familiarization with the full set of included articles. Full texts were uploaded into NVivo (Lumivero) to support organization of the dataset, systematic identification of relevant excerpts, and retrieval of coded segments. During this stage, both researchers read and re-read the articles to identify text related to strategic levers and associated activities, responsibility perspectives, responsibility framing orientations, action behaviors, and contextual factors. Early coding was conducted in close collaboration, with regular discussion to establish a shared understanding of how key constructs were expressed across studies. As patterns emerged, PR and AT articulated preliminary coding rules, definitions, and decision criteria, which were documented and refined iteratively in what became Appendix 2.

As the analysis progressed, PR and AT continued coding in an iterative and coordinated manner, guided by Braun and Clarke’s six-phase approach [115]. This involved identifying relevant excerpts, generating initial codes, reviewing and refining these codes across articles, and organizing them into higher-order thematic categories aligned with the conceptual framework. Appendix 2 evolved alongside this process and served as a shared analytic reference point, capturing construct definitions, guiding analytic questions, inclusion and exclusion criteria, and illustrative traceability examples. As coding became more stable, PR and AT divided articles for efficiency while maintaining regular check-ins to discuss ambiguous cases and ensure continued alignment in how the coding rules were applied.

The broader four-member research team (PR, AT, NB, and VM) was engaged at key points in the analytic process to support consistency and critical reflection. After PR and AT completed initial coding and developed a preliminary set of coding rules across approximately half of the included articles, materials including coded excerpts, emerging themes, draft analytic definitions, and relevant source articles, were shared in advance with NB and VM. The full team then met to review the developing coding structure, discuss areas of ambiguity, and refine definitions and decision boundaries reflected in Appendix 2. Following this midpoint discussion, PR and AT continued coding the remaining articles using the refined approach. A second full-team meeting was held after coding was completed across all included studies. Again, materials were shared in advance, and the team reviewed overall patterns, consistency of coding, and the coherence of final themes. Differences in interpretation were discussed and resolved through consensus, with reference back to the original text and the established coding rules as needed.

Consistent with reflexive thematic analysis, the goal of this process was not to achieve statistical agreement, but to develop a transparent and well-reasoned interpretation grounded in the data. Several steps were taken to support analytic rigor. First, researcher roles were clearly defined, with PR and AT leading the analytic process and NB and VM providing structured opportunities for review and critical input. Second, the analytic process was documented in a stepwise and transparent manner through the development and refinement of Appendix 2, which captures how codes and themes were derived from verbatim excerpts. Third, reflexivity was maintained through ongoing discussion, comparison of interpretations, and return to source text when questions arose. Finally, transparency was ensured by maintaining clear links between data and findings through traceability examples and structured coding rules. All interpretive decisions were made by the research team. These elements align with key dimensions of qualitative reporting guidance, including the Consolidated Criteria for Reporting Qualitative Research (COREQ) [116], particularly with respect to researcher roles, the analytic process, reflexivity in interpretation, and transparency in linking data to findings, while remaining appropriate for a qualitative evidence synthesis of published literature rather than primary data collection contexts. The complete charting matrices for all included studies are provided in Appendix 6, and the full raw dataset containing all charted variables in spreadsheet form is provided in Appendix 7.

Process for synthesizing results

Synthesis was guided by the integrated conceptual framework and the five research questions. Given the heterogeneity of included sources, synthesis focused on identifying cross-study patterns rather than comparing individual studies. Descriptive synthesis established the structural and contextual landscape of equity-oriented initiatives across U.S. health systems, including variation by organizational type, SD-DOH domains addressed, and outcome orientation. Non-mutually exclusive coding was intentionally retained for many descriptive variables to reflect the real-world complexity of multi-dimensional initiatives.

Analytic synthesis centered on examining alignment between responsibility perspectives and strategic levers used (observed equity-oriented action). For RQ3, responsibility domains and framing orientations were analyzed in relation to strategic levers using cross-tabulation to assess how articulated responsibility co-occurred with downstream, midstream, and upstream strategies. This approach enabled systematic examination of whether and how responsibility framing translated into equity action. Additional analyses examined variation in responsibility perspectives across organizational types (RQ4) and synthesized responsibility framing alongside identified barriers, facilitators, and accountability structures to assess readiness and capacity for equity-oriented work (RQ5).

Results

Results are presented in Tables 1, 2, 3, 4, 5, 6, 7, 8 and 9 and aligned with the five research questions (RQs). Table 1 summarizes article characteristics, while Table 2 describes organizational context and equity-oriented initiative characteristics (RQ1). Table 3 synthesizes the strategic levers used by initiatives (RQ1). Tables 4 and 5 shift from observed action to responsibility framing, summarizing domains and typologies of how leaders and organizational stakeholders frame what health systems should do to address social and digital determinants of health (SD-DOH) (RQ2). Tables 6, 7, 8 and 9 then extend this analysis by examining alignment between responsibility perspectives and equity-oriented strategies (RQ3), variation in responsibility perspectives by organizational type (RQ4), and implications for readiness and strategic capacity to advance equity-oriented work (RQ5).

Table 1.

Evidence-base characteristics

Category	Description	n	%
A. Geographic Scope1
National (U.S.-wide; explicitly national scope)	Studies explicitly framed at a national level or spanning multiple U.S. states/regions	34	36%
Multi-state regional (≥ 2 states, sub-national)	Studies conducted across several states or regions but not nationally representative	18	19%
State-level	Studies focused on a single U.S. state	15	16%
Metropolitan / urban area	Studies centered on a specific city or metropolitan area (e.g., NYC, Los Angeles, Philadelphia)	17	18%
County or local jurisdiction	Studies focused on a county, municipality, or local service region	7	7%
Single health system or multi-site system catchment	Studies anchored in one health system or integrated delivery network (often spanning multiple localities)	22	23%
B. Study Design2
Qualitative empirical studies		56	60%
Quantitative empirical studies		23	24%
Mixed methods studies		19	20%
Case studies		20	21%
Conceptual, commentary, or policy analyses		19	20%
Reviews (systematic, scoping, or narrative)		3	3%
Other designs		5	5%
C. Population context3
Low-income and socioeconomically marginalized populations	Populations characterized by poverty, financial strain, housing insecurity, or limited material resources	46	49%
Racially and ethnically marginalized populations	Populations defined by race/ethnicity, including Black, Hispanic/Latino, Indigenous, and other communities experiencing structural racism	38	40%
Medically underserved or safety-net populations	Patients served in FQHCs, safety-net hospitals, Medicaid-dominant systems, or resource-constrained care settings	35	37%
Immigrant, refugee, or limited-English-proficiency populations	Immigrant, refugee, asylum-seeking populations, or those facing language and cultural access barriers	22	23%
Patients with complex health or social needs	Individuals with multimorbidity, behavioral health conditions, disability, or high social risk	27	29%
Children, adolescents, and families	Pediatric populations, school-aged children, adolescents, and family-centered contexts	19	20%
Rural or geographically marginalized communities	Rural, frontier, or geographically isolated populations with access constraints	14	15%
Digitally marginalized populations	Populations experiencing digital exclusion, limited broadband access, low digital literacy, or technology barriers	16	17%
Other or unspecified populations	Studies with broad, mixed, or non-specific population framing	11	12%
D. Funding or Incentive Mechanism4
Public insurance programs (Medicaid, Medicare, CHIP)	Funding or incentives tied to public insurance coverage, reimbursement, or program requirements	42	45%
Value-based payment and alternative payment models	ACOs, bundled payments, shared savings, pay-for-performance, or other value-based arrangements	28	30%
Government grants or public funding	Federal, state, or local grants supporting equity, SD-DOH, or system transformation initiatives	24	26%
Health system or institutional investment	Internal funding, operational budgets, or strategic investments by health systems or organizations	31	33%
Philanthropic or foundation funding	Support from private foundations or philanthropic organizations	18	19%
Research funding (federal or foundation)	Research-specific grants supporting evaluation, implementation, or conceptual work	21	22%
No specific funding mechanism reported	Studies that did not explicitly describe funding or incentive structures	17	18%

¹Geographic scope categories are not mutually exclusive. Individual studies were often coded at more than one geographic level (for example, a metropolitan setting and a single health system catchment area). As a result, the total number of geographic scope codes exceeds the number of studies included (N = 94)

²Study design categories were not mutually exclusive. Each study was coded for all design types that were clearly reflected in the paper (e.g., a mixed methods case study that also used interviews and qualitative process analysis was coded as mixed methods, case study, and qualitative empirical). “Other designs” includes scholarly dissertations and trade journal articles that did not align neatly with standard empirical, conceptual, or review classifications. Percentages are based on N = 94 studies included

³Population focus categories are not mutually exclusive. Individual studies frequently addressed multiple population groups within a single initiative or analysis. Counts reflect the number of studies in which each population context was present; therefore, totals exceed the number of studies included (N = 94)

⁴Funding and incentive mechanism categories are not mutually exclusive. Individual studies frequently reported multiple funding sources or incentives supporting a single initiative (for example, public insurance reimbursement combined with grant funding or internal health system investment). Counts reflect the number of studies in which each funding mechanism was reported; therefore, totals exceed the number of studies included (N = 94)

Table 2.

Organizational context & equity initiative characteristics

Category	Description	n	%
A. Organizational Type1
Multi-Sector Partnerships & Coalitions	Initiatives organized through formal collaboration among multiple sectors, such as health systems, community-based organizations, primary care providers, or technology partners. These initiatives are not led by a single organization; instead, planning and implementation are described as shared across partners working toward common goals.	51	54.3%
Hospitals & Health Systems	Initiatives led by hospitals, integrated delivery systems, or academic medical centers, including primary care practices owned by health systems. Academic health systems are included when initiatives are implemented through healthcare delivery operations rather than through a standalone university or research center.	36	38.3%
Primary Care & Community Health Providers	Initiatives led by Federally Qualified Health Centers, Community Health Centers, or independent primary care clinics that are not owned or operated by hospital systems. System-owned primary care practices are not included in this category.	5	5.3%
Community-Based Organizations (CBOs)	Initiatives led by community-based or nonprofit organizations such as social service providers or advocacy groups, where the organization itself is the primary driver of planning and implementation.	1	1.1%
Technology, Data & Infrastructure Organizations	Initiatives led by organizations focused on digital platforms, data systems, analytics, or technology infrastructure, rather than health or social service delivery.	1	1.1%
Total		94	100%
B. Stakeholder Group2
Clinical leaders or providers		39	41.5%
Administrators or managers		22	23.4%
Health system leaders or executives		15	16.0%
Community partners or CBO representatives		9	9.6%
Public health or policy officials		5	5.3%
Patients or consumer advocates		3	3.2%
Payers or insurer representatives		1	1.1%
Total		94	100%
C. Leadership Level3
Executive leadership		32	34.4%
Mid-level leadership		29	31.2%
Frontline leadership		18	19.4%
Multi-level leadership (explicitly cross-tier)		14	15.1%
Total		93	100%
D. Equity Depth4
Awareness-level	Focuses on identifying inequities, gaps, or unmet needs, often through measurement or problem description, without describing substantive action to address them	18	19.1%
Implementation / practice-level	Describes equity-oriented practices integrated into routine care or operations, such as screening, referrals, navigation, workflow changes, or use of digital tools	29	30.9%
Capacity-building	Emphasizes building organizational ability to support equity work over time, such as leadership roles, staffing, training, data systems, or governance structures	21	22.3%
Transformational / system-level	Targets structural or system drivers of inequity, such as power sharing with communities, policy or financing change, cross-sector investment, or redesign of care and accountability systems	26	27.7%
Total		94	100%
E. Stage of Implementation5
Planning or design	Initiatives focused on needs assessment, planning, stakeholder engagement, or program design, with limited or no implementation underway	18	19.8%
Pilot or early implementation	Initiatives in early rollout or pilot testing phases, often emphasizing learning, refinement, or feasibility	27	29.7%
Active implementation	Initiatives actively delivered at scale within organizations or communities, often with ongoing monitoring or adaptation	32	35.2%
Sustained or institutionalized	Initiatives embedded into routine operations, policies, or organizational structures, indicating longer-term continuation	14	15.4%
Total		91	100%
F. Outcome Orientation6
Process outcomes	Focuses on how equity initiatives are carried out, such as staff training, documentation practices, screening processes, workflows, referrals, or use of digital tools	29	31.9%
Intermediate outcomes	Reflects early results of implementation, such as screening completion, referrals made, patient engagement, navigation uptake, or use of digital health tools	26	28.6%
Clinical outcomes	Describes patient-level clinical indicators, such as disease control, symptoms, utilization, or hospital readmissions	12	13.2%
Social outcomes	Addresses social or community conditions, such as food security, housing stability, broadband access, or technology access	15	16.5%
System-level outcomes	Describes organizational or system changes, such as care model redesign, governance or accountability changes, policy shifts, or financing reforms	9	9.9%
Total		91	100%
G. SD-DOH Domains7
Health Care Access and Quality	Access to timely, affordable, and high-quality clinical care, including continuity, coordination, and culturally responsive services	82	87%
Neighborhood and Built Environment	Housing, transportation, physical environment, safety, and neighborhood conditions shaping health and access	79	84%
Economic Stability	Income, employment, financial strain, food security, and material resources	73	78%
Social and Community Context	Social support, discrimination, racism, community cohesion, civic participation, and social networks	54	57%
Education Access and Quality	Educational attainment, health literacy, language access, and skills needed to navigate systems	53	56%
Digital Domain	Digital access, broadband, devices, digital literacy, or use of digital tools such as electronic health records, patient portals, telehealth platforms, mobile health applications, and data systems as part of equity-oriented care delivery or implementation.	43	46%
Multiple or integrated domains (≥ 3 domains)	Initiatives addressing three or more SD-DOH domains simultaneously through integrated or systems-based approaches	86	92%
H. Overall Orientation of Equity Initiatives8
Downstream only	Initiatives focused primarily on enabling services to mitigate individuals’ immediate social or digital needs, without additional midstream or upstream levers	19	20%
Downstream–Midstream	Initiatives that include enabling services to address individual social or digital needs (e.g., screening, referral, navigation), combined with community partnership, care coordination, or organizational process changes to embed these services into routine practice	38	40%
Downstream–Upstream (Policy)	Initiatives that include enabling services alongside policy, regulatory, or financing advocacy aimed at addressing structural or system-level drivers of inequity	23	25%
Downstream–Upstream (Structural/Investment)	Initiatives combining enabling services with direct community or anchor-based investment strategies	1	1%
Midstream only	Initiatives centered on community partnership, organizational redesign, or workflow integration, without a direct enabling services component	3	3%
Upstream (Structural/Investment) only	Initiatives primarily targeting structural inequities, governance, or system accountability, without an explicit enabling services component	7	7%
Upstream (Policy) only	Initiatives focused specifically on policy or financing reform in the absence of direct enabling services	2	2%
Mixed or other orientations	Initiatives with atypical or less clearly specified combinations of strategic levers	1	1%
Total		94	100%

¹Organization type was classified at the initiative level using a configuration-based approach. Each study was assigned to a single organization type that best reflects how the equity-oriented initiative was primarily organized and coordinated. This differs from a presence-based approach, which would count all organizational types mentioned within a study. Multi-Sector Partnerships & Coalitions refer to initiatives organized through formal collaboration among multiple organizations, where responsibility for planning and implementation is shared across partners rather than housed within a single organization. While many initiatives involved hospitals or other partners, initiatives were classified as multi-sector when responsibility was described as jointly organized rather than led by one entity. Percentages are based on N = 94 included studies

²Stakeholder group was summarized at the level of the initiative. Although many studies referenced multiple stakeholder groups, each initiative was assigned a primary stakeholder perspective based on whose voice most clearly shaped how responsibility for addressing SD-DOH was framed and discussed. This approach was used to keep initiative characteristics comparable across Table 2 and to support analyses linking organizational context, responsibility framing, and action. Percentages are based on N = 94 included studies

³Leadership level reflects the primary leadership perspective emphasized in each initiative. Each study was assigned a single leadership level based on which actors were most central to decision-making, responsibility framing, or implementation as described in the study. One study did not provide sufficient information to support classification and was excluded from this summary, resulting in a total of 93 classified initiatives. Percentages may not sum to exactly 100% due to rounding

⁴Equity depth reflects the primary orientation of each initiative toward equity, based on how equity goals were described and operationalized. Although many studies referenced multiple equity-related activities, each initiative was classified according to the highest or most advanced equity orientation evident in the study. Percentages are based on N = 94 included studies and may not sum to exactly 100% due to rounding

⁵Implementation stage reflects the primary stage described for each initiative. Three conceptual or policy-focused studies did not describe an implemented initiative and were excluded from this summary. Percentages may not sum to exactly 100% due to rounding

⁶Outcome orientation reflects the primary outcome emphasis of each initiative. Three conceptual or policy-focused studies did not report outcomes associated with an implemented initiative and were excluded from this summary. Percentages may not sum to exactly 100% due to rounding

⁷SD-DOH domain categories are not mutually exclusive. Individual studies frequently addressed multiple SD-DOH simultaneously; therefore, counts reflect the number of studies in which each domain was addressed, and percentages exceed 100%. N = 94 included studies

⁸Orientation categories reflect dominant combinations of strategic levers across downstream (enabling services), midstream (community partnership), and upstream (policy advocacy or investment) levels. When enabling services were present alongside other levers, initiatives were classified as downstream–midstream or downstream–upstream to reflect the foundational role of downstream action. Percentages are based on N = 94 included studies

Table 3.

Strategic levers used by equity-oriented initiatives: frequency, dominant activity types, lever combinations, and examples

PANEL A: Strategic Levers: Frequency and Dominant Activity Types
Strategic Lever	n	%	Dominant Activity Types
Enabling services	81	86.2%	Screening for social and digital needs; referral and navigation to community resources; care coordination and follow-up; integration of screening tools and referral workflows into EHRs; digital navigation and patient support at the point of care.
Community partnerships	66	70.2%	Formal partnerships with community-based organizations; co-development of referral pathways and service networks; shared governance or coordination structures; culturally and linguistically tailored outreach delivered with trusted community partners.
Policy advocacy	32	34.0%	Engagement with payers and policymakers; participation in waiver programs and payment reform initiatives; advocacy for data-sharing standards, reimbursement for social care, and regulatory changes to support equity-oriented practice.
Direct community investment	8	8.5%	Financial and in-kind investments in communities, including support for housing-related services, workforce development, anchor institution strategies (hiring, purchasing), and infrastructure investments tied to long-term community well-being.
None identified	1	1.1%	No equity initiative was implemented; the study focused on stakeholder perspectives on care utilization rather than describing a specific strategy or intervention.
PANEL B: Patterns of Lever Combinations and Examples
Strategic Lever Combination	n	%	Illustrative Examples
Enabling services	19	20.2%	Social risk screening was built into routine care so staff could identify needs and connect patients to help during visits, with emphasis on how relationships and workflow shape follow-through (Bunce et al., 2023) [62]. A health system prepared to use a predictive risk tool to flag high-need, high-cost patients and guide supportive care planning, focusing on transparency and workflow fit for end users (Benda et al., 2020) [63].
Enabling services; Community partnerships	38	40.4%	Primary care practices screened for social needs and “brokered” resources by building referral pathways and warm handoffs with community organizations for food, housing, transportation, and related needs (Fraze et al., 2021) [57]. Community organizations serving Asian American LGBTQ communities described culturally and linguistically tailored supports and linkages to services that address social stressors and access barriers (Matthews et al., 2022) [61].
Enabling services; Policy advocacy	6	6.4%	Emergency departments expanded care coordination and transitional support for patients as part of Maryland’s payment reform environment, showing how policy incentives shape operational social care work (Galarraga et al., 2021) [69]. Hospitals described technical and policy barriers to exchanging data across settings and highlighted where standards and policy changes are needed to strengthen health information infrastructure (Walker et al., 2021) [86].
Enabling services; Community partnerships; Policy advocacy	13	13.8%	Oregon’s Accountable Health Communities work illustrated cross-sector screening and referral networks and how perceived organizational risks and governance challenges can shape multi-sector collaboration under policy-driven models (Petchel et al., 2020) [59]. A safety-net system created a collaboration team to expand social service partnerships and referral infrastructure across countywide initiatives aligned with waiver-driven priorities (Carson et al., 2024) [71].
Enabling services; Community partnerships; Direct community investment	1	1.1%	A rural county hospital described combining direct service supports with local partnerships and community investment strategies (including workforce and community resource supports) to remain viable while addressing social challenges in its service area (Campos, 2022) [14].
Enabling services; Community partnerships; Policy advocacy; Direct community investment	4	4.3%	Health systems described programs to support unhoused patients (such as medical respite and service partnerships) and the operational and financing realities that shape what can be sustained and scaled (Potter et al., 2020) [43]. A primary care civic engagement framework described using health care touchpoints to support participation, partner with community institutions, and advance upstream policy and investment strategies tied to equity (Habib et al., 2023) [39].
Community partnerships	3	3.2%	A place-based coalition model showed how cross-sector partners built and sustained collaboration over time in a low-resource neighborhood, emphasizing shared purpose and network functioning (Madondo et al., 2022) [110]. Community-based organizations described how health care’s growing interest in SDOH changed expectations for collaboration and affected how CBOs positioned themselves as partners (Taylor et al., 2021) [114].
Community partnerships; Policy advocacy	4	4.3%	CBOs described their role in Medicaid redesign efforts, including how they provided input through public processes and where partnership expectations did not match resourcing or implementation realities (Tsering et al., 2023) [68]. Health system purchasing professionals described how equity considerations can be built into procurement decisions and how purchasing can be used to influence broader market and policy conditions (Hauschildt et al., 2025) [67].
Community partnerships; Policy advocacy; Direct community investment	3	3.2%	A conceptual “anchor” approach described how hospitals can use hiring, purchasing, and local investment strategies in partnership with communities to strengthen community well-being and address root causes (Weston et al., 2020) [41]. Stakeholders developed shared measurement principles to advance equity, emphasizing power-sharing, cross-sector accountability, and using measures to guide systems and policy decisions (Hilliard-Boone et al., 2022) [72].
Policy advocacy	2	2.1%	National stakeholders described concerns about bias in health care algorithms and outlined policy and governance solutions such as standards, transparency, and accountability to reduce harm (Jain et al., 2023) [70]. A conceptual framework on hospital transfer networks highlighted structural and policy-relevant design issues that can affect access and equity in emergency care across communities (Hsuan et al., 2023) [60].
None identified	1	1.1%	This study examined perspectives on why preventable high utilization occurs (patients, physicians, and leaders) but did not evaluate an implemented equity initiative, so no strategic levers could be identified (Das et al., 2020) [51].
Total	94	100%

Strategic levers are not mutually exclusive. Individual initiatives frequently employed multiple levers simultaneously; therefore, counts and percentages exceed 100%. Panel A summarizes the overall frequency of each strategic lever across studies. Panel B summarizes common combinations of strategic levers used together within individual initiatives. “None identified” refers to a study (Das et al., 2020) [51] that examined stakeholder perspectives on preventable health care utilization but did not describe an implemented equity-oriented initiative and therefore could not be classified under any strategic lever. Percentages are based on N = 94 included studies

Table 4.

Domains of responsibility framing reflected in leader and stakeholder perspectives on SD-DOH

Domain	Brief Definition	n	% of Studies	Illustrative Examples
Awareness	Responsibility to recognize, document, and make sense of social and digital needs and structural inequities (e.g., seeing SD-DOH as central to outcomes, using data to identify disparities).	57	61%	• Surgeons in an academic medical center describe an ethical obligation to “recognize” SDOH in patients’ lives but emphasize lacking time, tools, or pathways (Sullivan et al., 2024) [33]. • Nurses in hospital settings frame SDOH awareness as part of “good nursing practice,” asking about food, housing, and safety (Phillips et al., 2020) [34]. • Public health and academic leaders describe structural competency and equity literacy as foundational awareness responsibilities (Hilts et al., 2021) [1].
Assistance	Responsibility to help patients/families address immediate barriers, typically through navigation, Community Health Workers (CHWs), resource linkage, or digital support.	64	68%	• Clinicians and trainees routinely connect patients to food, housing, transportation, childcare, or behavioral health resources (Nederveld et al., 2022) [38]. • FQHC CHW models assist with forms, benefits, scheduling, and social service coordination (Lewis et al., 2023) [66]. • In digital care, staff help patients log in to portals or telehealth platforms or pivot to in-person care when digital barriers disrupt access (Vilendrer et al., 2024) [15].
Adjustment	Responsibility to adapt clinical roles, workflows, and tools so that SD-DOH work is integrated into routine care rather than ad hoc.	61	65%	• Primary-care teams implement universal SDOH screening and embed CHWs and social workers (Nederveld et al., 2022) [38]. • Pediatric asthma programs co-produce accessible, culturally resonant materials and workflows using PDSA cycles (Margolis et al., 2025) [4]. • Digital equity initiatives embed SDOH flags, digital navigators, or risk scores directly into EHR workflows (Benda et al., 2020) [63].
Alignment	Responsibility to build and maintain cross-sector alignment with community partners, Community-Based Organizations (CBOs), public agencies, and other systems around shared equity goals.	78	83%	• Medicaid ACOs, payers, CBOs, and health systems emphasize shared stewardship and aligned incentives (Durfey et al., 2022) [32]. • FQHC leaders co-govern clinical and community cancer-equity initiatives (Carson et al., 2023) [71]. • Digital equity partnerships stress co-design, community expertise, and non-extractive governance (Kim & Backonja, 2024) [26].
Advocacy	Responsibility to advocate for structural change (e.g., policy reform, payment redesign, anti-racism initiatives, broadband or civic reforms).	30	32%	• Academic leaders highlight social accountability and the need for Medicaid reform and structural anti-racism policies (Caruana et al., 2024) [35]. • Coalitions like LATIN-19 advocate for language access, immigration protections, and equitable working conditions (Plasencia et al., 2024) [52]. • Algorithm governance papers call for fairness audits, federal oversight, and standardized equity metrics (Jain et al., 2023) [70].
System governance & accountability	Responsibility to create governance, data, and accountability structures that hold organizations and systems responsible for equity outcomes.	56	60%	• Health systems and payers describe dashboards, shared measurement, and cross-sector governance structures (Durfey et al., 2022) [32]. • Regional frameworks (e.g., NET-EQUITY-type models) frame responsibility as redesigning regulatory and contracting structures for equitable access (Hsuan et al., 2023) [60]. • Digital/AI governance papers emphasize ethical oversight, fairness audits, transparency, and organizational accountability for acting on identified risk (Jain et al., 2023) [70].

Responsibility framing domains are not mutually exclusive. Individual studies frequently reflected multiple domains of responsibility within leader and stakeholder perspectives (for example, recognizing social needs, assisting patients, and coordinating with community partners). Counts indicate the number of studies (N = 94) in which each responsibility domain appeared at least once. Percentages represent the proportion of studies included that reflected each domain and therefore exceed 100%. Illustrative examples are drawn from representative studies and are not exhaustive

Table 5.

Typology of responsibility framing reflected in leader and stakeholder perspectives on SD-DOH

Responsibility Framing Type	Brief Definition	n	%	Typical Responsibility Framing Domains	Illustrative Examples
1. Responsibility to address individual needs	Frames healthcare responsibility as identifying and responding to patients’ immediate social and digital needs as part of direct care, emphasizing individualized assessment, navigation, and short-term assistance to mitigate barriers to access and outcomes. Common action behaviors include screening, referral, navigation, and point-of-care support.	17	18%	Awareness; Assistance (with secondary Adjustment)	Hospital and primary care teams describe implementing routine screening for food insecurity and other HRSNs and then directly connecting patients to resources through referral pathways and navigation support (Nederveld et al., 2022) [38]. A systematic review of hospital HRSN screening highlights the same patient-level responsibility logic of identifying needs during care encounters and responding with concrete linkage and assistance (Trochez et al., 2023) [13].
2. Responsibility to improve care processes and workflows	Frames responsibility as integrating SD-DOH and digital equity work into routine clinical operations by redesigning workflows, roles, tools, and care pathways so that equity-oriented practices are systematic rather than ad hoc. Common action behaviors include workflow redesign, EHR integration, role expansion, and quality improvement cycles.	15	16%	Adjustment; Awareness (with secondary Assistance)	A pragmatic implementation effort embeds standardized SBDOH screening and “enhanced navigation” into routine workflows, emphasizing operational integration rather than ad hoc referrals (Reddy et al., 2025) [44]. A quality-improvement case study shows how teams revise clinical processes and tools using structured feedback and equity-focused design decisions to reduce implementation burden and inequitable rollout (Chandler et al., 2024) [53].
3. Responsibility to build and govern organizational capacity	Frames responsibility as an organizational and leadership obligation to establish governance, infrastructure, and accountability mechanisms that enable sustained equity action. Emphasizes leadership commitment, measurement systems, data governance, and internal accountability for SD-DOH and digital equity outcomes.	23	24%	System governance & accountability; Awareness; Adjustment	A health center leadership fellowship is designed to build organizational and leadership capacity for transformation and equity, developing leaders’ competencies, governance capability, and systems-change skills (Lewis et al., 2023) [66]. Frontline leaders in a safety-net integrated system describe the need for leadership supports, organizational infrastructure, and accountable management practices to sustain workforce wellbeing and equity-oriented operations (Wallace et al., 2025) [56].
4. Responsibility to partner and share power with communities and CBOs	Frames responsibility as a relational and shared endeavor between health systems and communities, emphasizing co-design, trust-building, and power-sharing with CBOs and community stakeholders. Common action behaviors include partnership governance, co-production, and shared decision-making structures.	9	10%	Alignment; System governance & accountability (with secondary Advocacy)	Medicare Advantage plan representatives describe formal partnerships with CBOs to address enrollees’ social needs, emphasizing shared roles, contracting arrangements, and capacity-building to make partnerships workable and non-extractive (Durfey et al., 2022) [32]. A community capacity-building initiative supported by county-level funding illustrates cross-sector co-development of community-driven solutions positioned at the interface of health systems and local community organizations (Gilmer et al., 2025) [45].
5. Responsibility to address structural inequities and racism	Frames responsibility as confronting and dismantling structural inequities, including racism and other forms of systemic exclusion, that shape health and digital outcomes. Emphasizes organizational self-examination, anti-racist reform, and structural competency beyond individual-level interventions.	4	4%	Advocacy; Awareness; System governance & accountability	A community health center “health justice” framing emphasizes that equity requires confronting structural inequities as part of the organization’s mission and practice, not only meeting individual needs (Waite & Nardi, 2024) [45]. An FQHC response for immigrant and refugee communities during COVID-19 highlights structural barriers (e.g., access constraints) and the responsibility to address these inequities through culturally and linguistically responsive strategies (Norton & Thielman, 2021) [113].
6. Responsibility to influence policy and financing systems	Frames responsibility as extending beyond organizational boundaries to influence policy, payment, and regulatory environments that enable or constrain equity-oriented work. Common action behaviors include policy advocacy, engagement with payers, and efforts to reform financing and incentive structures.	16	17%	Advocacy; Alignment (with secondary System governance & accountability)	A national stakeholder survey shows how organizations procure and use SDOH data and highlights the need for broader standardization, incentives, and system-level policy support to enable meaningful data use (Heidari et al., 2022) [36]. A multi-sector policy analysis of contraceptive access describes persistent structural barriers and frames responsibility as addressing coverage and financing gaps through policy and system reform (Lassar et al., 2021) [77].
7. Responsibility to community accountability and anchor investment	Frames responsibility as long-term accountability to place and community wellbeing, positioning health systems as anchor institutions with obligations to invest resources, purchasing power, and institutional influence to advance community-level equity.	1	1%	System governance & accountability; Alignment; Advocacy	Hospitals are framed as “anchor institutions” responsible for improving community wellbeing by leveraging economic power, i.e., local hiring, purchasing, and long-term institutional investment aligned with community needs and accountability (Weston et al., 2020) [41].
8. Responsibility to close the digital divide and steward technology ethically	Frames responsibility as ensuring equitable access to digital health technologies and governing their use ethically, emphasizing digital inclusion, transparency, fairness, and protection from harm. Common action behaviors include digital navigation, infrastructure investment, ethical oversight, and algorithmic governance.	9	10%	Awareness; Adjustment; Advocacy (with System governance & accountability)	Community-based organizations describe digital inclusion as prerequisite to equitable access and call for shared stewardship, including digital literacy support, access infrastructure, and community-informed design of digital health solutions (Kim & Backonja, 2024) [26]. A qualitative policy-focused synthesis highlights concern about racial/ethnic bias in clinical algorithms and frames responsibility as ethical governance, including transparency, oversight, and mitigation strategies to prevent digital harms (Jain et al., 2023) [70].

Responsibility framing types represent a dominant framing logic identified for each study, based on how leaders or stakeholders most centrally described healthcare organizations’ responsibilities for addressing social and digital determinants of health. Each study was assigned to a single responsibility framing type to support analytic clarity and comparison across initiatives. Typical responsibility framing domains indicate the most commonly associated domains within each framing type, but individual studies may reflect additional domains. Percentages are based on N = 94 included studies

Table 6.

Alignment between responsibility domains and strategic levers

Responsibility Domain 1,2	Enabling services (n = 81)	Community partnerships (n = 66)	Policy advocacy (n = 32)	Direct community investment (n = 8)	None identified (n = 1)
Awareness (n = 57)	49 (60.5% | 86%)	39 (59.1% | 68%)	20 (62.5% | 35%)	6 (75.0% | 11%)	1 (100% | 2%)
Assistance (n = 64)	63 (77.8% | 98%)	50 (75.8% | 78%)	18 (56.2% | 28%)	5 (62.5% | 8%)	0 (0% | 0%)
Adjustment (n = 61)	60 (74.1% | 98%)	40 (60.6% | 66%)	14 (43.8% | 23%)	3 (37.5% | 5%)	0 (0% | 0%)
Alignment (n = 78)	67 (82.7% | 86%)	66 (100% | 85%)	27 (84.4% | 35%)	8 (100% | 10%)	0 (0% | 0%)
Advocacy (n = 30)	20 (24.7% | 67%)	23 (34.8% | 77%)	24 (75.0% | 80%)	7 (87.5% | 23%)	1 (100% | 3%)
System governance & accountability (n = 56)	44 (54.3% | 79%)	37 (56.1% | 66%)	24 (75.0% | 43%)	8 (100% | 14%)	0 (0% | 0%)

¹Cells show, n (column % | row %), where column % represents the proportion of initiatives using a given strategic lever that reflect the responsibility domain, and row % represents the proportion of initiatives reflecting a given responsibility domain that use the strategic lever

²Responsibility domains and strategic levers are not mutually exclusive. Each cell shows the number of studies coded with both the responsibility domain and the strategic lever. Column percentages indicate the proportion of initiatives using a given strategic lever that reflect the responsibility domain. Row percentages indicate the proportion of initiatives reflecting a given responsibility domain that use the strategic lever

Table 7.

Organization type distribution within responsibility domains

Responsibility Domain 1,2	Hospitals & Health Systems (n = 36)	Primary Care & Community Health Providers (n = 5)	Community-Based Organizations (CBOs) (n = 1)	Multi-Sector Partnerships & Coalitions (n = 51)	Technology, Data & Infrastructure Organizations (n = 1)
Awareness (n = 57)	19 (33.3%)	1 (1.8%)	1 (1.8%)	36 (63.2%)	0 (0.0%)
Assistance (n = 64)	23 (35.9%)	4 (6.2%)	1 (1.6%)	35 (54.7%)	1 (1.6%)
Adjustment (n = 61)	30 (49.2%)	4 (6.6%)	0 (0.0%)	26 (42.6%)	1 (1.6%)
Alignment (n = 78)	27 (34.6%)	5 (6.4%)	1 (1.3%)	44 (56.4%)	1 (1.3%)
Advocacy (n = 30)	7 (23.3%)	2 (6.7%)	0 (0.0%)	21 (70.0%)	0 (0.0%)
System governance & accountability (n = 56)	21 (37.5%)	1 (1.8%)	0 (0.0%)	34 (60.7%)	0 (0.0%)

¹Cells shown as n (% within responsibility domain row)

²Organization type was coded at the initiative level. Each initiative was assigned a single organization type reflecting how responsibility was primarily organized, even when multiple organizations were involved. Initiatives structured around shared governance or cross-sector coordination were classified as Multi-Sector Partnerships & Coalitions. Responsibility domains are not mutually exclusive. Cells show the number of initiatives within each responsibility domain, with row percentages indicating the distribution of organization types within that domain

Table 8.

Organization type distribution within responsibility framing themes

Responsibility Framing Theme 1,2	Hospitals & Health Systems (n = 36)	Primary Care & Community Health Providers (n = 5)	Community-Based Organizations (CBOs) (n = 1)	Multi-Sector Partnerships & Coalitions (n = 51)	Technology, Data & Infrastructure Organizations (n = 1)
1. Responsibility to address individual needs (n = 17)	6 (35.3%)	0 (0.0%)	1 (5.9%)	10 (58.8%)	0 (0.0%)
2. Responsibility to improve care processes and workflows (n = 15)	8 (53.3%)	2 (13.3%)	0 (0.0%)	5 (33.3%)	0 (0.0%)
3. Responsibility to build and govern organizational capacity (n = 23)	8 (34.8%)	0 (0.0%)	0 (0.0%)	15 (65.2%)	0 (0.0%)
4. Responsibility to partner and share power with communities and CBOs (n = 9)	1 (11.1%)	1 (11.1%)	0 (0.0%)	7 (77.8%)	0 (0.0%)
5. Responsibility to address structural inequities and racism (n = 4)	1 (25.0%)	1 (25.0%)	0 (0.0%)	2 (50.0%)	0 (0.0%)
6. Responsibility to influence policy and financing systems (n = 16)	6 (37.5%)	1 (6.2%)	0 (0.0%)	9 (56.2%)	0 (0.0%)
7. Responsibility to community accountability and anchor investment (n = 1)	0 (0.0%)	0 (0.0%)	0 (0.0%)	1 (100.0%)	0 (0.0%)
8. Responsibility to close the digital divide and steward technology ethically (n = 9)	6 (66.7%)	0 (0.0%)	0 (0.0%)	2 (22.2%)	1 (11.1%)

¹Cells shown as n (% within responsibility domain row)

²Organization type was classified at the initiative level using a configuration-based approach, whereby each study was assigned to a single organization type reflecting how responsibility for the initiative was primarily organized. Initiatives structured as formal collaborations across multiple sectors were classified as Multi-Sector Partnerships & Coalitions to capture shared organization of responsibility. Cells show the number of initiatives within each responsibility framing theme, with row percentages indicating the distribution of organization types within that theme. Percentages may not add up to exactly 100% due to rounding

Table 9.

Barriers, facilitators, and accountability structures

Category	n	%	Description
A. BARRIERS
Resource and capacity constraints within health systems and partner organizations	46	48.9%	Limited staffing, time, funding, and operational capacity within health systems and partner organizations that constrained the ability to design, implement, or sustain equity-oriented initiatives.
Data, technology, and interoperability challenges	29	30.9%	Challenges related to EHR limitations, lack of data standards, poor interoperability, burdensome documentation, and difficulties sharing data across organizations and sectors.
Policy, reimbursement, and regulatory barriers	24	25.5%	Unclear or misaligned reimbursement mechanisms, short-term or uncertain funding, regulatory complexity, and policy constraints that limited incentives or feasibility for equity work.
Workforce limitations and burnout	21	22.3%	Staff shortages, role strain, burnout, insufficient training, and limited workforce readiness to take on additional equity-related responsibilities.
Digital divide and access barriers	18	19.1%	Limited patient access to broadband, devices, digital literacy, or accessible technologies that constrained participation in digital or technology-enabled initiatives.
Fragmented systems and poor cross-sector coordination	17	18.1%	Misalignment across healthcare, social services, public health, and community organizations, leading to duplication, gaps in services, and inefficient coordination.
Community trust, engagement, and power imbalances	14	14.9%	Historical mistrust, lack of community voice in decision-making, extractive partnerships, and insufficient power-sharing with communities and CBOs.
Structural inequities and racism	13	13.8%	Persistent structural racism, discrimination, and social inequities embedded within institutions, policies, and practices that undermine equity efforts.
Organizational culture and leadership misalignment	12	12.8%	Competing priorities, weak leadership commitment, risk aversion, or lack of shared vision that limited organizational readiness for equity-oriented change.
Sustainability and scale challenges	9	9.6%	Difficulty sustaining or scaling initiatives beyond pilot phases due to funding cliffs, staffing turnover, or lack of institutionalization.
B. FACILITATORS 2
Enabling policy and regulatory environment	43	45.7%	Policies, regulations, and national or state initiatives that made equity-oriented work more feasible, such as enabling rules, mandates, or formal program requirements that supported SD-DOH action.
Leadership commitment and equity-oriented culture	37	39.4%	Clear leadership support, champions, and an organizational culture that prioritizes equity and “whole-person” care, helping teams stay aligned and motivated.
Financing, reimbursement, and funding supports	17	18.1%	Grants, value-based payment models, or reimbursement pathways that created resources and incentives to implement and sustain equity initiatives.
Community partnerships, trust, and relationship-based work	13	13.8%	Strong relationships with CBOs and cross-sector partners, trust-building, shared goals, and collaboration structures that enabled effective coordination and follow-through.
Workforce capacity, training, and dedicated roles	10	10.6%	Availability of trained staff and dedicated roles (for example navigators, CHWs, care managers) and team-based capacity to carry out screening, referral, follow-up, and engagement activities.
Data and technology infrastructure	9	9.6%	EHR and HIT capabilities, data capacity, analytics, digital tools, and other technology infrastructure that supported implementation, tracking, or patient-facing access.
Workflow integration, measurement, and learning	4	4.3%	Clear workflows, practical guidance, iterative improvement, measurement/metrics, and tools that helped teams adapt and operationalize equity work over time.
Local context knowledge and resource awareness	2	2.1%	Local knowledge and on-the-ground understanding of community needs and resources that improved fit, targeting, and practical problem-solving.
C. ACCOUNTABILITY STRUCTURES3
Measurement, metrics, and performance monitoring	34	36.2%	Use of formal metrics, dashboards, reporting requirements, or performance indicators to track implementation progress, outcomes, or equity-related goals and hold teams accountable.
Leadership oversight and governance structures	31	33.0%	Executive sponsorship, board or senior leadership oversight, formal governance committees, or designated leadership roles responsible for equity and SD-DOH initiatives.
Policy, regulatory, or contractual accountability	27	28.7%	Accountability embedded in policies, regulations, payer requirements, contracts, waivers, or formal agreements that require or incentivize equity-related activities.
Cross-sector and partnership accountability mechanisms	22	23.4%	Shared accountability across healthcare organizations, CBOs, and public-sector partners through MOUs, shared governance, joint planning, or coordinated responsibility structures.
Organizational policies, procedures, and internal standards	19	20.2%	Internal policies, protocols, standards of practice, or organizational rules that institutionalize equity and SD-DOH responsibilities.
Financial accountability and incentive alignment	15	16.0%	Financial levers such as tied funding, payment models, incentive structures, or budgetary controls used to reinforce accountability for equity-related work.
Community accountability and feedback mechanisms	12	12.8%	Mechanisms for accountability to communities, including advisory boards, community councils, feedback loops, or participatory structures that elevate community voice.
Professional norms and ethical accountability	8	8.5%	Accountability grounded in professional values, ethical commitments, or normative expectations rather than formal measurement or policy requirements.
No explicit accountability structure identified	11	11.7%	Studies in which accountability mechanisms were implicit, diffuse, or not clearly articulated in relation to equity or SD-DOH initiatives.

¹Barrier categories are not mutually exclusive; frequencies reflect the number of studies in which each barrier was identified. Categories were synthesized from detailed, study-level barrier descriptions to support clear interpretation while preserving alignment with the original coded data. Percentages are based on N = 94 included studies

²Facilitator categories are not mutually exclusive; frequencies reflect the number of studies in which each facilitator type was identified. Categories were synthesized from the detailed facilitator entries in the raw data to support clear interpretation while preserving alignment with the original coded data. Percentages are based on N = 94 included studies

³Accountability structure categories are not mutually exclusive; frequencies reflect the number of studies in which each type of accountability mechanism was identified. Categories were synthesized from detailed study-level descriptions to support clear interpretation while preserving alignment with the original coded data. Percentages are based on N = 94 included studies

Section 1A. article characteristics (RQ1)

Table 1 summarizes the descriptive characteristics of the 94 studies included in this review, providing context for the analytic results that follow. These characteristics situate the evidence base in terms of geographic scope, study design, population focus, and funding environments.

Geographic scope

The literature reflects a mix of national and place-based perspectives (Table 1-A). Over one-third of studies were national in orientation (36%) [32], drawing on U.S.-wide or multi-state data [43], while others focused on regional (19%) or single-state contexts (16%) [71]. Place-based studies were also common [14], including metropolitan or urban settings, local jurisdictions, and single health system catchment areas [2]. Many studies connected broader policy or regulatory environments to localized implementation, reflecting a literature that bridges system-level context with organizational and community-level equity action. Geographic categories were not mutually exclusive, as many initiatives operated simultaneously across multiple levels.

Study design

The evidence base is predominantly qualitative and practice-oriented (Table 1-B), consistent with the review’s focus on leader and organizational stakeholder perspectives. Qualitative empirical designs were used in 60% of studies, with interviews, focus groups, observations, and document analysis most common [33]. Mixed-methods (20%) and quantitative studies (24%) were also represented [71]. Case studies accounted for approximately one-fifth of the sample [14], while conceptual, commentary, and policy-oriented papers comprised a similar proportion, underscoring the interpretive and normative orientation of the literature [39].

Population focus

Studies frequently addressed multiple populations simultaneously (Table 1-C). Nearly half focused on low-income or socioeconomically marginalized populations (49%), and 40% explicitly centered racially and ethnically marginalized groups. Medically underserved or safety-net populations appeared in over one-third of studies [56], with immigrant, refugee, limited-English-proficiency populations, and patients with complex health or social needs also represented across a substantial subset [47]. These overlapping categories reflect how equity-oriented initiatives commonly address intersecting forms of disadvantage rather than targeting single population groups in isolation.

Funding and incentive mechanisms

Reported funding and incentive mechanisms (Table 1-D) illustrate a fragmented and layered financing environment [16, 117]. Public insurance programs were most frequently cited (45%) [32], followed by health system or institutional investment (33%) [2], value-based or alternative payment models (30%), and government grants (26%). Many initiatives relied on blended financing across multiple sources, while nearly one-fifth of studies did not explicitly report funding mechanisms. Overall, these patterns highlight the complex financing contexts within which equity-oriented initiatives operate.

Section 1B. organizational context and initiative characteristics (RQ1)

Table 2 describes organizational configurations and initiative characteristics, providing context for later analyses of responsibility framing, strategy alignment, and readiness.

Organizational type

Using a configuration-based approach that classified initiatives by where responsibility for planning and action was primarily situated (Table 2-A), just over half of initiatives were organized as Multi-Sector Partnerships or Coalitions (54%). Although responsibility was shared across partners in these initiatives, most included hospitals or health systems as participating actors [32, 50]. Hospital- or health system-led initiatives accounted for 38% of the sample [33, 56], while initiatives led primarily by primary care or community health providers were relatively uncommon [45]. CBO-led and technology-led initiatives were rare. This distribution reflects the central role of health systems within broader cross-sector equity efforts.

Stakeholder group and leadership level

Stakeholder group (Table 2-B) was summarized based on the primary perspective emphasized in each study. Clinical leaders, administrators, and health system executives together accounted for the majority (81%) of primary stakeholder perspectives [2, 33, 45, 56], while community representatives [26], public health officials, patients, and payers [32] were less frequently centered. With respect to leadership levels (Table 2-C), executive perspectives were most common (34.4%) [35], followed by mid-level (31.2%) and frontline leadership (19.4%) [34].

Equity depth and implementation stage

Initiatives varied in how deeply equity considerations were embedded (Table 2-D). Implementation-focused initiatives were most common (30.9%), followed by transformational initiatives (27.7%) aimed at addressing structural inequities or reshaping systems through policy change or investments [45]. Capacity-building initiatives accounted for 22.3%, emphasizing development of organizational infrastructure, workforce skills, or data systems [4]. With respect to implementation stage (Table 2-E), most initiatives were beyond planning and actively implementing (35.2%) or piloting interventions (29.7%), but relatively few (15.4%) were described as fully sustained or institutionalized, indicating that much of the literature reflects work still in development.

Outcome orientation

Reported outcomes (Table 2-F) emphasized proximal and intermediate measures (61%), including process and intermediate outcomes, while fewer studies (39%) focused primarily on social, clinical, or system-level outcomes. In reported outcome orientation, therefore, this distribution indicates limited attention to measures of longer-term system change.

SD-DOH domains and downstream–upstream orientation

Initiatives commonly addressed multiple SD-DOH domains (Table 2-G), most frequently, healthcare access and quality, neighborhood and built environment, and economic stability. Digital determinants appeared in nearly half of studies, though explicit framing of digital equity or ethical technology stewardship as a core responsibility (10%) was uncommon [70]. When classified by downstream, midstream, and upstream orientation (Table 2-H), the most prevalent configuration combined downstream enabling services with midstream community partnership strategies (40%) [4]. Upstream approaches were less common overall and appeared most often as policy advocacy layered onto downstream enabling services (25%). Direct community or structural investment was rare and occurred predominantly as a stand-alone upstream strategy.

Section 2. strategic levers used by equity-oriented initiatives (RQ1)

This section examines the strategic levers health systems and their partners employed to address SD-DOH, capturing what organizations did in practice across the included studies. Strategic levers span downstream service-oriented approaches, midstream coordination strategies, and more upstream policy and investment actions. Results are presented first by overall prevalence and then by common combinations of levers used together (Table 3, Panels A & B).

Prevalence of strategic levers across studies

Across the 94 included studies, enabling services dominated equity-oriented action, appearing in 86.2% of initiatives (Table 3, Panel A). These efforts were centered on identifying and responding to individuals’ immediate social or digital needs through screening, referral, navigation, and care coordination [33], . Community partnerships were also widespread, present in 70.2% of studies, reflecting collaboration with community-based organizations, public health agencies, and other local partners to facilitate referrals, culturally tailored outreach, and service delivery [71, 110]. In contrast, upstream levers were substantially less prevalent. Policy advocacy appeared in 34.0% of studies [70], typically involving engagement with payment reform initiatives or data-sharing standards.

Direct community investment was rare, identified in only 8.5% of studies and most often involving housing-related services, workforce development, or anchor institution strategies [41]. Only one study did not describe an implemented equity initiative and therefore could not be classified under any strategic lever [51]. Overall, these findings indicate that equity-oriented work in U.S. health systems remains heavily concentrated in downstream and midstream approaches, with enabling services and community partnerships forming the backbone of most initiatives, while more upstream strategies remain relatively rare.

Figure 3 provides a visual summary of the distribution of strategic levers across studies. As shown, equity-oriented initiatives are heavily concentrated in enabling services and community partnerships, with substantially lower representation of policy advocacy and direct community investment. This distribution highlights the relative emphasis on downstream and midstream approaches compared to more upstream strategies.

Fig. 3.

Distribution of equity-oriented initiatives by strategic lever. This figure displays the proportion of included studies (n = 94) reporting the use of each strategic lever. The distribution shows a strong concentration in enabling services and community partnerships, with substantially lower representation of policy advocacy and direct community investment, indicating an emphasis on downstream and midstream approaches

Patterns of strategic lever combination

Examining lever combinations further underscores the centrality of downstream and midstream approaches (Table 2, Panel B). The most common configuration paired enabling services with community partnerships (40.4%), reflecting a dominant model in which health systems screen for needs and rely on external partners to broker resources. Only 4.3% of studies employed all four levers, simultaneously [2]. Taken together, these findings indicate that equity-oriented work in U.S. health systems remains heavily concentrated on downstream and midstream strategies, with enabling services and partnerships forming the backbone of action. Upstream approaches are present but limited, suggesting structural, financing, and governance constraints on sustained system-level intervention [43].

Section 3. how leaders and stakeholders frame responsibility for SD-DOH (RQ2)

Domains of responsibility framing

Table 4 summarizes domains of responsibility framing reflected in leader and organizational stakeholder perspectives. Domains are not mutually exclusive; most studies reflect multiple responsibility domains. The most prevalent domain is Alignment, appearing in 83% of studies, where responsibility is framed as coordinating efforts across health systems, community organizations, public agencies, and other sectors around shared equity goals [32]. Assistance is the second most common domain (68%), framing responsibility as helping individuals overcome immediate social or digital barriers to care through navigation, referrals, community health workers, or hands-on digital support. Closely related are Adjustment (65%) and Awareness (61%), which emphasize adapting workflows, tools, and recognizing social and digital needs through data, screening, and equity literacy [34]. Together, these domains highlight that responsibility is not only about helping individuals, but about embedding equity work into routine practice.

Two domains signal movement beyond individual encounters. System governance and accountability, appears in 60% of studies, reflecting responsibility to establish governance, measurement, and accountability structures for equity outcomes [45]. Advocacy, present in 32% of studies, frames responsibility as engagement with policy reform, payment redesign, anti-racism initiatives, or other structural changes beyond organizational boundaries [70]. Overall, these patterns show that responsibility is most often framed through operational or relational lenses, with explicit policy and structural advocacy less frequently articulated.

Figure 4 illustrates the distribution of responsibility domains across studies. Responsibility is most frequently framed in terms of alignment, assistance, adjustment, and awareness, with comparatively lower emphasis on advocacy and structural responsibility domains. This pattern reinforces the predominance of operational and relational framings of responsibility relative to more upstream or system-level perspectives.

Fig. 4.

Distribution of responsibility framing domains across studies. This figure illustrates the proportion of included studies (n = 94) reflecting each responsibility domain. Responsibility is most frequently framed through alignment, assistance, adjustment, and awareness, with comparatively less emphasis on advocacy and system governance and accountability, highlighting a predominance of operational and relational perspectives

Typology of responsibility framing themes

Table 5 synthesizes responsibility domains into eight responsibility framing types, each representing a dominant logic through which responsibility is articulated. The most common framing is Responsibility to build and govern organizational capacity (Type 3; 24%) [56, 66], which emphasizes leadership commitment, governance, measurement, and accountability as prerequisites for sustained equity action. Two additional framings reflect a strong operational orientation: Responsibility to address individual needs (Type 1; 18%) [34] and Responsibility to improve care processes and workflows (Type 2; 16%) [49, 53]. Together, these three types account for nearly 60% of studies, underscoring the predominance of downstream and midstream responsibility logics [38].

More expansive framings are less common but analytically important. Responsibility to influence policy and financing systems (Type 6; 17%) [69] and Responsibility to partner and share power with communities (Type 4; 10%) [32] position responsibility beyond organizational boundaries. Explicitly structural framings, Responsibility to address structural inequities and racism (Type 5; 4%) [45] and Responsibility to community accountability and anchor investment (Type 7; 1%), are rare [41]. Responsibility to close the digital divide and steward technology ethically (Type 8; 10%) [70] reflects a still limited recognition of digital equity or inclusion as a core responsibility. These patterns indicate that responsibility is most often framed in ways compatible with downstream and midstream action, while more structural and place-based responsibility claims remain uncommon.

Section 4. alignment between responsibility framings and equity strategies (RQ3–RQ5)

This section examines alignment between responsibility framings, and the equity strategies initiatives employ (RQ3), variation in these patterns across organizational contexts (RQ4), and what combined patterns of action, barriers, facilitators, and accountability structures suggest about readiness and capacity to advance equity-oriented work (RQ5). Tables 6, 7 and 8 assess alignment across responsibility domains, strategic levers, and organizational types, while Table 9 contextualizes these patterns.

Alignment between responsibility domains and strategic levers

Table 6 examines alignment by assessing co-occurrence between responsibility domains and strategic levers using both column and row percentages.

Downstream & midstream alignment

Awareness, Assistance, and Adjustment show strong alignment with enabling services and community partnerships. From the column perspective, among initiatives using enabling services, 60.5% reflect Awareness, 77.8% Assistance, and 74.1% Adjustment. From the row perspective, nearly all initiatives reflecting Assistance (98%) and Adjustment (98%) also employ enabling services, and substantial majorities also use community partnerships (78% and 66%, respectively). These patterns indicate that responsibility framings centered on recognizing needs, helping individuals, and adapting workflows are tightly coupled with downstream and midstream strategies. Alignment is the most prevalent responsibility domain across all strategic levers. It appears in 82.7% of enabling services initiatives, 100% of community partnership initiatives, 84.4% of policy advocacy initiatives, and 100% of direct community investment initiatives. From the row perspective, 86% of initiatives reflecting Alignment use enabling services and 85% use community partnerships, underscoring coordination and shared purpose as foundational across all levels of action.

Upstream patterns and limits

Advocacy and direct community investment show more selective alignment. From the column perspective, Advocacy appears in 75.0% of policy advocacy initiatives and 87.5% of direct community investment initiatives, but in only 24.7% of enabling services initiatives and 34.8% of community partnership initiatives. From the row perspective, 80% of initiatives reflecting Advocacy, use policy advocacy, while smaller proportions also pair advocacy with enabling services (67%) or community partnerships (77%). These patterns indicate that advocacy-oriented responsibility framings occur most when initiatives are explicitly designed around upstream levers.

System governance & accountability functions as a cross-cutting domain. It appears in 54.3% of enabling services initiatives, 56.1% of community partnership initiatives, 75.0% of policy advocacy initiatives, and 100% of direct community investment initiatives. From the row perspective, 79% of initiatives reflecting this domain use enabling services, 66% use community partnerships, and 43% use policy advocacy. This pattern indicates that governance and accountability capacity is often developed alongside downstream and midstream work and becomes especially prominent as initiatives extend upstream.

Overall, Table 6 demonstrates strong empirical alignment between responsibility framings and equity strategies. Downstream and midstream responsibility domains align closely with enabling services and partnerships, while advocacy-oriented framings align primarily with upstream levers. System governance & accountability, spans all levels, suggesting emerging governance capacity even where action remains downstream and midstream.

To facilitate interpretation of these patterns, Fig. 5 presents a heatmap that complements Table 6 by visualizing co-occurrence using column percentages. Column percentages indicate the proportion of initiatives using a given strategic lever that reflects each responsibility domain, allowing comparison of relative prevalence across levers. The heatmap highlights strong alignment between Alignment and all strategic levers, as well as higher co-occurrence of Advocacy with policy advocacy and direct community investment, while Awareness and Adjustment show more moderate or variable patterns across levers. Table 6 provides the corresponding detailed counts and both column and row percentages.

Fig. 5.

Heatmap of alignment between responsibility domains and strategic levers. This heatmap complements Table 6 by visualizing patterns of co-occurrence between responsibility domains and strategic levers. The heatmap is based on column percentages, which represent the proportion of initiatives using a given strategic lever that reflects each responsibility domain, enabling comparison of relative prevalence across levers. Darker shading indicates higher prevalence, while lighter shading indicates lower prevalence of co-occurrence. Table 6 provides the corresponding exact counts and both column and row percentages

Organizational context of responsibility domains

Table 7 examines how responsibility domains are distributed across organizational types, addressing RQ4. Across all responsibility domains, Multi-Sector Partnerships account for the largest share of initiatives: 63.2% of initiatives reflecting Awareness, 54.7% Assistance, 42.6% Adjustment, 56.4% Alignment, 70.0% Advocacy, and 60.7% System governance and accountability. This indicates that responsibility framing is most frequently articulated within initiatives structured across sectors rather than housed within a single organization.

Hospitals and health systems represent the second-largest category across domains, accounting for between 23.3% (Advocacy) and 49.2% (Adjustment) of initiatives. Hospitals are most prominent in domains tied to operational integration, particularly Adjustment (49.2%) and Assistance (35.9%), consistent with their role in redesigning workflows, staffing models, and care processes. Primary care providers, CBO-led initiatives, and technology-led initiatives each account for small proportions across domains, rarely exceeding single-digit percentages. Overall, Table 7 shows that responsibility domains are most often articulated within multi-sector organizational contexts, with hospitals playing a central but not exclusive role. Operational responsibility domains cluster more strongly within hospital-led initiatives, while broader structural responsibility domains appear most often where responsibility is shared across sectors.

Organizational context of responsibility framing themes

Table 8 extends the organizational analysis to responsibility framing themes. Multi-Sector Partnerships and Coalitions account for the majority of initiatives framed around building and governing organizational capacity (Type 3; 65.2%), partnering and sharing power with communities and CBOs (Type 4; 77.8%), and influencing policy and financing systems (Type 6; 56.2%). The single initiative framed around community accountability and anchor investment (Type 7) is also classified as multi-sector, reflecting shared governance and accountability.

In contrast, health systems are most prominent in framing themes focused on internal operations and technology-mediated implementation. They account for 53.3% of initiatives framed around improving care processes and workflows (Type 2) and 66.7% of initiatives framed around closing the digital divide and stewarding technology ethically (Type 8). Together, Tables 7 and 8 demonstrate that expansive framings involving shared power, governance, and policy influence are most often articulated within multi-sector contexts, while hospitals more frequently frame responsibility through operational and technology-oriented lenses.

Section 5. readiness and capacity for advancing equity-oriented work (RQ5)

Table 9 contextualizes alignment patterns by examining barriers, facilitators, and accountability structures (RQ5). Barriers most frequently involve resource and capacity constraints within health systems and partner organizations (48.9%), followed by data, technology, and interoperability challenges (30.9%), and policy, reimbursement, and regulatory barriers (25.5%). Workforce limitations and burnout (22.3%), digital divide barriers (19.1%), fragmented coordination (18.1%), community trust and power imbalances (14.9%), and structural inequities and racism (13.8%) further constrain action (Table 9-A).

Facilitators most often include enabling policy and regulatory environments (45.7%) and leadership commitment and equity-oriented culture (39.4%). Financing support (18.1%) and strong community partnerships (13.8%) appear less frequently, and workflow integration, measurement, and learning infrastructure is reported in only 4.3% of studies (Table 9-B).

Accountability structures most commonly involve measurement and performance monitoring (36.2%) and leadership oversight (33.0%), followed by policy or contractual accountability (28.7%) and cross-sector mechanisms (23.4%). Community accountability appears in 12.8% of studies, while 11.7% report no explicit accountability structure (Table 9-C).

Overall, Table 9 indicates that while many initiatives face substantial constraints, a meaningful subset has developed leadership, governance, and measurement structures consistent with the system governance and accountability domain observed in Table 6. These patterns help explain the dominance of downstream and midstream action and the relative scarcity of upstream strategies, setting the stage for interpretation in the Discussion.

Discussion

Summary of key findings

This scoping review synthesized leader and organizational stakeholder perspectives on health system responsibility for SD-DOH and examined whether those responsibility framings align with observed equity-oriented action across U.S. health systems. Figures 3 and 4 provide a visual summary of the distribution of strategic levers and responsibility domains across studies. As shown in Fig. 3, equity-oriented action is concentrated in enabling services and community partnerships, with substantially lower use of policy advocacy and direct community investment. In parallel, Fig. 4 shows that responsibility is most frequently framed through alignment, assistance, adjustment, and awareness, while advocacy and system governance and accountability are less commonly articulated as domains of responsibility. Together, these patterns indicate that both action and responsibility framing are concentrated in downstream and midstream approaches, with more upstream engagement remaining limited.

The findings do not depict a field stalled at a starting point. Instead, they point to a field at an inflection point. Many organizations are already engaged in equity-oriented work through operational, governance, and partnership mechanisms that make equity actionable within health systems. As reflected in the concentration of activity within enabling services and community partnerships (Fig. 3), much of this work is occurring in areas where health systems have clearer operational control and established implementation pathways. At the same time, movement toward more upstream engagement remains selective, uneven, and strongly shaped by governance capacity, cross-sector accountability, and external policy conditions. This is further reflected in the comparatively limited presence of policy advocacy and direct community investment (Fig. 3), alongside less frequent framing of responsibility in terms of advocacy and system governance and accountability (Fig. 4).

Importantly, these findings must be interpreted within a shifting and uncertain U.S. sociopolitical context. While recent federal policy signals suggest reduced emphasis on equity-focused priorities, core delivery system reforms established under the Affordable Care Act, including value-based payment models, community benefit requirements, and population health accountability, remain in place. As a result, health systems continue to face increasing pressure to deliver value in the context of rising inequities and uncompensated care burdens. This creates a persistent economic and operational rationale for equity-oriented action, even in the absence of consistent federal policy support. In this sense, the field’s “inflection point” may be better understood not as a linear transition, but as a period of tension in which organizational commitment, financial incentives, and policy environments are not fully aligned.

Three cross-cutting patterns are discernible. First, downstream and midstream strategies dominate the evidence base. Enabling services and community partnerships appear most frequently [50], often bundled together and sometimes paired with policy advocacy. Direct community investment appears far less often as a primary strategy. Second, responsibility framing is closely aligned with action. How leaders and organizational stakeholders articulate responsibility maps onto the strategic levers organizations pursue, particularly for downstream and midstream work. This alignment between responsibility framing and observed action is further illustrated in the heat map (Fig. 5), which shows consistent co-occurrence patterns across studies. Third, barriers and facilitators reveal a maturity story rather than a checklist of technical gaps (e.g., tools or training). The most consequential constraints are relational and organizational, including trust, power, role clarity, and cross-sector alignment, layered on top of policy, financing, and regulatory challenges [32, 59].

Together, these findings suggest that moving upstream is not simply a matter of expanding existing activities. It requires legitimacy, shared accountability, and alignment across actors about what equity-oriented progress entails. Upstream intervention is necessary because downstream and midstream approaches, while essential for addressing immediate needs, do not alter the structural conditions that generate inequities in the first place. Without upstream action, health systems risk repeatedly managing the consequences of social and digital disadvantage rather than reducing their underlying causes. Consistent with the patterns observed across studies (Figs. 3 and 4), upstream action remains comparatively limited and more contingent on governance capacity and external alignment than downstream and midstream efforts. For healthcare administrators, this distinction has practical implications. Sustained improvements in population health, cost containment, and equity are unlikely to be achieved without engagement in policy, investment, and cross-sector strategies that influence the broader conditions shaping health. In this sense, upstream engagement is not an optional extension of equity work, but a necessary component of long-term system performance and impact.

From this perspective, institutionalizing equity resembles earlier waves of health system transformation, such as public reporting and value-based care, where changes in governance, measurement, and accountability reshaped organizational priorities and sustained action over time. If equity is to be institutionalized in a similar way, it will require infrastructure that makes equity visible, governable, and shared, rather than episodic or dependent on individual champions [5, 17].

Overall alignment between responsibility framing and equity action

A central contribution of this review is the empirical demonstration that responsibility framing aligns with equity-oriented action. As shown in the alignment patterns (Fig. 5; Table 6), responsibility domains and strategic levers co-occur in consistent and non-random ways across studies. This alignment is strongest where health systems have clear operational authority and established accountability channels. When responsibility is framed around assisting individuals or adjusting care processes, organizations tend to pursue enabling services, referral networks, care team redesign, and partnership models that can be embedded into existing workflows. These strategies align with midstream infrastructure such as governance structures, data capture, performance monitoring, and leadership oversight.

In contrast, when responsibility framing extends to influencing external conditions, such as policy change or structural investment, action becomes more conditional and depends on whether governance arrangements and accountability structures are sufficiently mature to support commitments beyond organizational boundaries [69]. This distinction helps explain why responsibility framing related to advocacy and investment appears less frequently and is more strongly associated with multi-sector initiatives and environments where external alignment is already partially in place [32].

Equity action is concentrated in midstream strategies

The findings indicate that midstream strategies are not merely transitional steps between downstream services and upstream change. In much of the literature, midstream work is where equity becomes workable within health systems. This includes building governance and oversight structures, standardized partnership workflows, data capture and monitoring systems, and clearer leadership accountability for cross-sector coordination. Rather than implying a linear progression from downstream to upstream, the evidence suggests that many health systems concentrate on midstream strategies because they are both actionable within organizational control and necessary for sustained upstream engagement [71, 110]. When upstream strategies do appear, they tend to be accompanied by stronger alignment and accountability capacity, consistent with implementation frameworks that emphasize leadership engagement, readiness, and organizational fit as prerequisites for sustained change.

Sustaining cross-sector work: limits to moving from midstream to upstream action

A key insight from the barriers and facilitators analysis is that limits on upstream engagement are often relational and organizational rather than purely technical. Even when resources exist, initiatives struggle to scale when partnerships are brittle, roles are unclear, power is uneven, or trust is underdeveloped [59]. Cross-sector partnerships do not work on their own, and when health systems rely on CBOs without investing in their capacity, partnerships are more likely to break down than to support shared accountability. This helps explain why many initiatives remain concentrated in midstream partnership models but do not consistently transition into sustained upstream engagement. Studies highlight that when health systems impose data exchange, reporting, or performance expectations without commensurate support, partnerships become strained [32]. Durable equity-oriented work therefore requires investment in partner capacity, including contracting support, technical assistance, realistic reporting requirements, and bi-directional data sharing where appropriate. Relational stewardship emerges as a form of core infrastructure that differentiates initiatives that remain referral-focused from those that evolve toward shared governance and broader influence.

Policy advocacy as a feasible upstream pathway

Policy and reimbursement constraints appear frequently as barriers, while enabling policy environments appear as facilitators [43]. This pattern underscores that advocacy is not optional if health systems intend to move beyond assistance and adjustment. Compared with direct community investment, policy advocacy often represents the most attainable upstream strategy, particularly for organizations with foundational governance capacity. Advocacy in this context functions as a strategic lever that could reshape the feasibility conditions for equity-oriented work [69]. Organizations have potential to pursue advocacy alongside enabling services and partnerships, using aggregate data to inform policy change. In this sense, advocacy can allow systems to influence the external rules that shape what equity work can be sustained at scale.

System governance, accountability, and capacity for upstream action

The review shows that governance and accountability structures, including leadership oversight and performance monitoring, are widely discussed. Importantly, Table 6 shows that system governance and accountability is already embedded in commonly used strategies, with column percentages indicating its presence in over half of enabling services (54.3%) and community partnerships (56.1%). At the same time, system governance and accountability becomes increasingly universal as strategies move upstream, present in 75.0% of policy advocacy initiatives and 100% of direct community investment efforts. Complementing this, row percentage patterns show that when system governance and accountability is present, it is most frequently expressed through enabling services (79%) and community partnerships (66%), rather than through policy advocacy (43%) or direct community investment (14%). Together, these patterns suggest that system governance is both foundational and scaling: it is widely embedded in downstream and midstream work, while also becoming nearly indispensable for upstream strategies, positioning commonly used approaches as a base for building capacity toward more sustained upstream engagement.

However, mechanisms for community accountability and shared learning infrastructure appear less consistently [41]. This gap points to a critical next step for institutionalizing equity: the development of shared measurement approaches co-created with communities and cross-sector partners and embedded into governance and accountability systems. Shared measurement does more than support evaluation. It clarifies what progress means across actors and enables accountability that extends beyond individual organizations [72].

Digital determinants: widely present but not yet centered as equity work

Digital components are present across many initiatives, yet explicit framing of digital equity as a core domain of responsibility remains limited [63, 70]. Across the reviewed studies, digital elements are most often incorporated as enabling tools, implementation support, or operational constraints within broader SD-DOH initiatives, rather than as central targets of equity-oriented action. This pattern is consistent with responsibility framing findings, where digital equity appears as a distinct framing logic in a relatively small subset of studies (Table 5; Theme 8, n = 9, 10%), indicating that it remains a secondary rather than primary organizing focus of responsibility.

At the same time, organization-level patterns suggest that hospitals and health systems are particularly well positioned to address the digital divide. Table 8 shows that 66.7% of initiatives explicitly framed around digital responsibility are led by hospitals and health systems, compared to lower representation from multi-sector partnerships and minimal representation from other organization types. This suggests that, unlike some upstream social determinants that require cross-sector coordination, digital access and infrastructure may fall more directly within the operational and governance scope of health systems.

When viewed alongside broader SD-DOH patterns in this review, digital determinants appear to follow a similar trajectory: they are most often addressed through downstream and midstream mechanisms, such as access support, workflow integration, and implementation of digital tools, but are less frequently framed as upstream structural priorities requiring sustained investment or policy engagement. This positioning may limit the extent to which digital transformation contributes to reducing inequities, particularly as digital tools increasingly shape access, quality, and patient experience.

The findings suggest that digital equity remains under-integrated into the core conceptualization of equity-oriented health system action. Health systems increasingly govern digital tools that influence care delivery, yet without explicit integration of equity into digital governance, these tools may inadvertently reproduce or exacerbate disparities. Elevating digital determinants as a core domain of equity responsibility would require moving beyond implementation toward governance, accountability, and investment strategies that address access, infrastructure, bias, and community-defined needs. This includes assessing algorithmic bias, ensuring accessibility, monitoring differential uptake, and involving affected communities in defining what equitable digital care entails [70].

While this review is focused on the United States, the patterns we observe align with a growing global focus on advancing health equity and digital inclusion within learning health systems. This global body of work highlights that efforts to address social and digital determinants are often concentrated in implementation and service delivery, with more limited progress toward sustained upstream action targeting structural drivers of inequity [30]. In this context, our findings add to a limited, but growing, evidence base by examining how responsibility for addressing SD-DOH is articulated in U.S. health system literature, and how these perspectives align with observed patterns of equity-oriented action. By making this connection explicit, the study provides a clearer empirical basis for understanding how health systems can move from implementation-focused efforts toward more sustained upstream engagement, a challenge reflected both within the United States and in broader global efforts.

Implications for practice, policy, and research

For practice, the findings suggest that relationship infrastructure and governance infrastructure are equity infrastructure. Durable initiatives invest not only in services, but in partnership capacity, shared accountability, and leadership oversight. Downstream and midstream work should be leveraged intentionally as scaffolding for upstream sustained engagement rather than treated as endpoints.

For policy, institutionalization requires incentives that support cross-sector governance, capacity-building for community partnerships, and shared accountability. Current U.S. approaches have largely emphasized screening and referral, which risk reinforcing downstream orientations while leaving relational and accountability infrastructure under-resourced. At the same time, policy signals remain inconsistent, with evolving federal priorities and variability across states creating uncertainty for long-term investment. In this context, health systems and stakeholders could advocate for policies that (1) reimburse social care activities beyond screening, including navigation and partnership coordination; (2) provide sustained funding for community-based organizations to support equitable partnerships; (3) enable shared measurement and accountability frameworks across health and social sectors; and (4) strengthen value-based payment models that incorporate equity-oriented outcomes. These directions would help align financial and regulatory environments with the governance and relational infrastructure required for durable equity-oriented work.

For research, future studies should examine equity work as a process of governance maturation rather than as isolated programs. Longitudinal research is needed to understand how initiatives evolve from enabling services and partnerships toward advocacy and structural change, and which governance and relational mechanisms support that evolution. Further research is also needed to develop measures of partnership quality, power sharing, community accountability, and alignment capacity, as well as to examine governance practices that prevent digital transformation from widening disparities.

Building on this dataset, future work could also examine relationships between equity depth, funding mechanisms, and sustainability of initiatives. For example, subgroup analyses could assess whether transformational or system-level equity efforts are more likely to be supported by institutional investment versus external grant funding, and the implications of these patterns for long-term scalability and sustained impact.

Limitations and strengths of the review

This scoping review has several limitations that should be understood as analytic boundaries rather than weaknesses, alongside strengths that enhance its contribution to the literature on health system responsibility for social and digital determinants of health. First, as a scoping review, this study was designed to map how responsibility is framed and operationalized across equity-oriented initiatives, rather than to assess effectiveness or causal impact. We did not evaluate intervention effectiveness, nor did we exclude studies based on methodological rigor. This approach was appropriate given the study’s focus on synthesizing leader and organizational stakeholder perspectives across a diverse body of evidence. However, it limits conclusions about which strategies are most effective in improving equity outcomes. The findings instead provide a foundation for future evaluative, comparative, and longitudinal research.

Second, the qualitative evidence synthesis relied on published and gray literature that varied widely in depth and reporting quality. Some studies included rich quotations and detailed descriptions of governance, partnerships, and implementation processes, while others offered more limited accounts. Although we used a systematic coding approach and preserved verbatim excerpts where available, uneven reporting influenced what could be synthesized. This reflects the current state of the literature and highlights the need for more consistent reporting on governance and community engagement in equity-oriented health system initiatives.

Third, responsibility domains and strategic levers frequently overlapped. Many initiatives reflected multiple responsibility framings and combined downstream, midstream, and upstream strategies; and the analysis allowed for this overlap. While this limits simple categorical comparisons, it more accurately reflects how equity-oriented work occurs in practice and should be viewed as a substantive finding rather than a limitation.

Fourth, the evidence base primarily reflects the perspectives of health system leaders, administrators, and clinicians, which is consistent with the review’s focus on leadership and organizational stakeholder perspectives. While community partnerships were widely described, community members were less frequently centered in discussions of governance, accountability, and power sharing. As a result, explicit mechanisms for community-defined accountability and shared decision-making were reported less consistently. This limits insight into how responsibility is experienced and interpreted by those most directly affected by inequities and highlights an important area for future research.

Finally, the review reflects a specific temporal and policy context. Most studies were published between 2020 and 2025, a period shaped by the COVID-19 pandemic, heightened attention to structural racism, rapid digital health expansion, and evolving policy and payment environments. These conditions likely influenced both the strategies emphasized and the barriers reported. The findings should therefore be interpreted as reflective of this dynamic period rather than as fixed features of the field.

Balanced against these limitations are several strengths. This review integrates responsibility framing with observed equity-oriented action, organizational context, and readiness, moving beyond descriptive summaries of initiatives. By examining how responsibility perspectives align with strategic levers and governance structures, the study offers a clearer explanation of how equity work becomes actionable and sustained within health systems.

In addition, the review draws on a large and diverse evidence base, spanning empirical studies, policy analyses, and conceptual work across healthcare, public health, and digital equity. The use of an extended responsibility framework, grounded in the NAM 5 A model and expanded to include system governance and accountability, provides a novel contribution that helps link responsibility claims to organizational capacity for action. Together, these strengths enhance the study’s relevance for researchers, practitioners, and policymakers seeking to understand not only what health systems are doing to address SD-DOH, but how responsibility framing shapes readiness for longer-term equity-oriented transformation.

Conclusion

This scoping review examined how health system leaders and organizational stakeholders frame responsibility for addressing social and digital determinants of health, how those framings align with equity-oriented action, how patterns vary across organizational contexts, and what barriers, facilitators, and accountability structures reveal about readiness for sustained equity work. Taken together, the findings depict a field at an inflection point rather than at an early stage of engagement. First, U.S. health systems are actively implementing equity-oriented initiatives, most commonly through enabling services and community partnerships. Responsibility framing aligns closely with these dominant strategies, indicating that responsibility functions as a practical lens shaping what organizations view as legitimate and actionable, rather than as a purely normative stance.

Second, midstream strategies focused on alignment, adjustment, and system integration represent the core infrastructure of current equity work. These strategies translate values into governance, operations, and accountability, making equity actionable within health systems. Rather than serving only as a bridge to upstream action, midstream work appears to be the primary mechanism through which equity becomes durable and governable.

Third, upstream engagement remains selective and context dependent. Policy advocacy emerges as the most attainable upstream strategy, particularly for organizations with established governance and accountability capacity. Direct community investment is less common, reflecting the higher coordination and shared accountability requirements involved. The relative scarcity of upstream strategies reflects structural and relational constraints rather than lack of commitment.

Finally, readiness for equity-oriented transformation is shaped as much by relational and organizational dynamics as by technical capacity. Trust, partnership quality, aligned incentives, and accountability infrastructure repeatedly emerge as conditions that enable initiatives to move beyond referral-based models toward shared governance and structural influence.

In sum, responsibility framing matters. How health systems define their role in addressing inequities shapes not only what actions are taken, but which futures are seen as possible. By clarifying the alignment between responsibility, strategy, and organizational context, this study provides a foundation for more intentional, accountable, and transformative equity-oriented work in health systems.

Abbreviations

CBO

Community-Based Organization

CFIR

Consolidated Framework for Implementation Research

CHNA

Community Health Needs Assessment

CINAHL

Cumulative Index to Nursing and Allied Health Literature

CMS

Centers for Medicare & Medicaid Services

COH

Culture of Health

EHR

Electronic Health Record

FQHC

Federally Qualified Health Center

HHS

U.S. Department of Health and Human Services

HRSN

Health-Related Social Need(s)

LHS

Learning Health System(s)

MeSH

Medical Subject Headings

NAM

National Academy of Medicine

PRISMA-ScR

Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews

RQ

Research Question

RWJF

Robert Wood Johnson Foundation

SDOH

Social Determinants of Health

SD-DOH

Social and Digital Determinants of Health

Authors’ contributions

PR conceptualized and led the review. PR, AT, NB, and VM conducted data charting and contributed to analytic discussions throughout the review process. PR and AT led the Phase 2 thematic coding and interpretive synthesis. NB and VM primarily supported structured data charting and contributed to iterative discussions informing interpretation of coding decisions and analytic variables. PR prepared the original draft of the manuscript. PR, AT, NB, and VM contributed to revising and finalizing the manuscript by providing critical feedback on successive drafts. All authors reviewed and approved the final manuscript.

Funding

No specific external funding was received for the conduct of this study.

Data availability

The data analyzed in this study is included in the supplementary material (Additional file 7).

Declarations

Ethics approval and consent to participate

Are not applicable to this scoping review of the literature. All methods were carried out in accordance with relevant guidelines and regulations.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.