Advocacy to reduce disparities in SDOH

Collaborative Learning Community


We are intentionally multicultural

and believe that we are better at finding our strengths to address social determinants of health if we work together. Using appreciative Inquiry, active listening and collaborative decision making we share best practices, advocate for community members to be chosen as CHWs  recognizing their community health expertise and inviting them to the table where community health policy is decided. 

Improve Social Determinants of Health (SDOH)


Life experience and training make Community Health Workers (CHWs) experts in the social determinants of health. 

 CHWs advocate for social justice and equity across all parameters of life

Build Healthy Communities


Community Health Workers know that postal code has more impact on health outcomes than genetic code. 

We work to improve the places where we live, learn, work, pray and play 


Ecological model of SDOH

Additional Information

Ecology identifies environmental factors and influences, which interact and affect individual behavior. These factors may be the physical setting or place, the human aggregate or characteristics of the people, organizational and social climate, and/or characteristics of the surrounding community. (NASPA, 2004, p. 7)

Because significant and dynamic interrelationships exist among these different levels of health determinants, interventions are most likely to be effective when they address determinants at all levels. Historically, the health field has focused on individual-level health determinants and interventions. (U.S. Department of Health and Human Services, 2008, para. 18)

In the ecological model health status and behavior are the outcomes of interest (McLeroy, Bibeau, Steckler & Glanz, 1988, p. 355) and viewed as being determined by the following:

  • Public policy — Local, state, national, and global laws and policies.
    • Includes polices that allocate resources to establish and maintain a coalition that serves a mediating structure connecting individuals and the larger social environment to create a healthy campus. Other policies include those that restrict behavior such as tobacco use in public spaces and alcohol sales and consumption and those that provide behavioral incentives, both positive and negative, such as increased taxes on cigarettes and alcohol. Additional policies relate to violence, social injustice, green policies, foreign affairs, the economy, global warming.
  • Community — Relationships among organizations, institutions, and informational networks within defined boundaries.
    • Includes location in the community, built environment, neighborhood associations, community leaders, on/off-campus housing, businesses (e.g., bars, fast food restaurants, farmers markets), commuting, parking, transportation, walkability, parks.
  • Institutional factors — Social institutions with organizational characteristics and formal (and informal) rules and regulations for operations.
    • Includes campus climate (tolerance/intolerance), class schedules, financial policies, competitiveness, lighting, unclean environments, distance to classes and buildings, noise, availability of study and common lounge spaces, air quality, safety.
  • Interpersonal processes and primary groups — Formal and informal social networks and social support systems, including family, work group, and friendship networks.
    • Includes roommates, supervisors, resident advisors, rituals, customs, traditions, economic forces, diversity, athletics, recreation, intramural sports, clubs, Greek life.
  • Intrapersonal factors — Characteristics of the individual such as knowledge, attitudes, behavior, self-concept, skills, and developmental history.
    • Includes gender, religious identity, racial/ethnic identity, sexual orientation, economic status, financial resources, values, goals, expectations, age, genetics, resiliency, coping skills, time management skills, health literacy and accessing health care skills, stigma of accessing counseling services.


McLeroy, K. R., Steckler, A. and Bibeau, D. (Eds.) (1988). The social ecology of health promotion interventions. Health Education Quarterly, 15(4):351-377. Retrieved May 1, 2012, from

National Association of Student Personnel Administrators. (2004). Leadership of a healthy campus: an ecological approach to student success.

U.S. Department of Health and Human Services, Secretary’s Advisory Committee. (2008, December 11). Phase I report: recommendations for the framework and format of healthy people 2020. Retrieved May 1, 2012, from

Further Reading / Resources

Bronfrenbrenner, U. (1979). The ecology of human development. Cambridge: Harvard Press.

Hochman, S., Kernan, W. (2011) A social-ecological model for addressing stress on the college campus. Retrieved May 9, 2012, from

Moses, K., Schoenfield, D., Swinford, P., Grizzell, J. (2011). Healthy campus: reintroducing the ecological model and collaboration for student learning outcomes(webinar). National Association of Student Personnel Administrators, Health in Higher Education Knowledge Community.

National Association of Student Personnel Administrators and American College Personnel Association. (2004). Learning reconsidered: A campus-wide focus on the student experience. Washington, D.C.: National Association of Student Personnel Administrators and the American College Personnel Association. Retrieved May 1, 2012, from

Robert Wood Johnson Foundation. (2010). A new way to talk about the determinants of health. Retrieved May 1, 2012, from

U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2011, November 15). Determinants of health. Retrieved May 1, 2012, from

Ecological Approach


Ecological Approach

Adapted from McLeroy, K. R., Steckler, A. and Bibeau, D. (Eds.) (1988). The social ecology of health promotion interventions. Health Education Quarterly, 15(4):351-377. Retrieved May 1, 2012, from 

Download article from: 

 1988-McLeroy-An_Ecological_Perspective_on_Health_Promotion_Programs. pdf/27



Imbalance in Housing Aid

Imbalance in Housing Aid: Mortgage Interest Deduction vs. Section 8

 By Andrew Woo, Chris Salviati


With the tax reform debate now fully underway, Apartment List examined the popular mortgage interest deduction (MID) and compared federal expenditure on the MID to spending on Section 8 rental assistance programs. In 2015, the MID cost the federal government $71 billion, more than double the $29.9 billion funding for Section 8. Additionally, the MID is a highly regressive benefit, with 85 percent of expenditure going to high-income households.

While more than half of high-income households claim the MID, only 11 percent of low-income households receive assistance with their housing costs. This results in $1,549 in government spending per household for high-income households, nearly four times the $416 spent per low-income household. Geographically, expensive coastal areas receive the most expenditure per household, led by San Francisco and San Jose at the metro level. Given the failure to allocate funds to those in need, we recommend reforming the MID to provide more benefit to low-income and middle-income homeowners, while reinvesting the savings in Section 8 programs to benefit low-income renters.


Late last month, the Trump administration released plans for a comprehensive overhaul of the federal tax code. As the reforms gather steam, a particular point of interest for the housing market is the impact of the proposed new legislation on the mortgage interest deduction (MID), which allows homeowners to claim a tax deduction equal to the amount of interest they paid on their home loan.

While administration officials, lawmakers, industry executives and housing experts fiercely debate the future of the home mortgage deduction, lost in the argument is the fact that the political battle centers on issues relevant primarily to wealthier homeowners, while disregarding the unmet needs of lower income renters. The debate overlooks remedies for the deeply underfunded Section 8 rent subsidy program that helps some of the country’s poorest Americans.

The mortgage interest deduction has long been a benefit enjoyed mostly by high-income households, living in more expensive homes, with a greater amount of interest to deduct and higher marginal tax rates. This dynamic has made the MID a “regressive” benefit to tax experts.

Additionally, the MID is available only to homeowners, though renters are far more likely to face issues with housing costs. Nationwide, 52 percent of renter households are cost burdened, spending more than 30 percent of their income on housing, compared to just 26 percent of owner households whose housing costs exceed that threshold, according to data from Census. The problem is particularly acute for low-income renters, 77 percent of whom are cost burdened.

Low-income renters receive help from the Section 8 federal rental assistance program, which is much more effective than the MID in allocating funds to those in need, but it suffers from underfunding. Federal expenditure on the MID totaled $71 billion in 2015, more than double the $29.9 billion that went to Section 8 that year. Thus, many households who qualify for Section 8 assistance are unable to access benefits,facing exceedingly long waitlists and difficulty finding landlords who accept the vouchers.

America would be well served if policymakers in the tax reform debate consider ways to reform the MID to reach less-wealthy Americans, while using the savings to boost funding for the country’s Section 8 program, easing long waitlists and increasing benefits for some of the country’s most vulnerable families.

History of Housing Aid


The history of U.S. tax policy on home mortgages starts in the early 20th century. In 1913, Congress passed the 16th Amendment, which established the modern federal income tax and allowed for the deduction of all interest. At the time, Americans rarely purchased their homes with mortgages, and Congress likely intended the interest deduction to apply primarily to interest as a business expense. 

It wasn’t until the mortgage industry expanded after World War II that homeowners started to widely take advantage of the interest deduction. Decades later, when Congress passed the Tax Reform Act of 1986, a Reagan administration initiative, the new legislation largely eliminated tax deductions on interest from personal loans, but kept the MID in place, with the justification that it was an important tool for encouraging home-ownership. Today, the MID represents the single largest federal expenditure on housing assistance.

While the MID only benefits homeowners, federal housing assistance for renters is provided primarily through Section 8 programs. The first federal programs to provide housing subsidies for low-income families began during the Great Depression with the Housing Act of 1937. Legislators amended this act repeatedly over time, including with the Housing and Community Development Act of 1974, which created the modern Section 8 program. 

Section 8 functions as a voucher program, in which low-income families lease a unit in the private market — referred to as “tenant-based” — or within a specified complex, referred to as “project-based.” Voucher recipients pay a portion of their income toward rent (usually 30 percent), with the voucher covering the remaining cost. While any low-income family can apply for Section 8 assistance, waiting lists are usually long and in many cities, they have been closed for years. Additionally, even those who receive Section 8 vouchers may have difficulty finding landlords who will accept them. Consequently, only a small share of low-income Americans actually benefit from Section 8 programs.

Screening for Social Determinants of Health

Understanding Provider Screening for Social Determinants of Health 


By Sara Heath

May 15, 2019 - As healthcare professionals increasingly recognize the importance of the social determinants of health (SDOH) on patient outcomes and care, it will be important for them to create strategies for provider screening of these social factors.

The medical industry is inching itself closer to creating a holistic health experience, developing social supports and community health programsthat target the downstream factors that influence a patient’s health.

But the success of these programs hinges on a provider’s ability to identify patients who would benefit from them. Without a sound provider screening process, efforts to address the SDOH will be for naught.

“A greater focus on social determinants of health can enable physicians to become stronger advocates for patients and to help reduce negative health outcomes that are often associated with social determinants of health,” said Jack Ende, MD, MACP, the president of the American College of Physicians in a recent call for better SDOH screening.

“Taking a closer look at social determinants of health can help us better understand and address the social factors that have an impact on patient health,” Ende added. “It’s important that physicians and other medical professionals recognize and account for social determinants of health to create a more comprehensive approach with our patients.”

READ MORE: How Medicaid Agencies Tackle the Social Determinants of Health

Currently, there is no evidence base for SDOH screening. Instead, healthcare professionals across the country, in partnership with some key industry leaders, are testing different methods for detecting and flagging patients who may benefit from social supports.


One study out of Massachusetts General Hospital (MGH) looked at natural language processing (NLP) and its ability to detect keywords indicating a social need.

The researchers deployed NLP on unstructured data – where most SDOH information would be located – in the EHRs of 132 adult patients. The program scanned for 22 SDOH keywords that could indicate that the patient experienced some sort of social need.

Specifically, the tool scanned records for the following terms: anxiety, depressed, sad, angry, neuro-vegetative, schizoaffective, substance, abuse, addict, AA, sober, cocaine, heroin, crack, mushrooms, prison, jail, homeless, shelter, stamps, stolen, and tox.

The tool found a mean of 14.1 of these terms for Medicaid patients, and six of these words for patients not enrolled in Medicaid. While this indicates that Medicaid patients are more likely than others to experience SDOH, it more so suggests that NLP could successfully identify these patients.

READ MORE: Kaiser Permanente Network to Address Social Determinants of Health

“Our novel approach offers the ability to use a patient’s EHR as a way to identify important psychosocial risk factors potentially driving or contributing to health care utilization and costs, and medical outcomes, among patients enrolled in Medicaid,” the research team stated.

“This study provides an important step forward for population health management by outlining a new method for identifying the important role that social determinants and mental health play in health outcomes, and offers a promising new approach to stratifying this risk burden on a population level.”


Other healthcare professionals are making headway through patient surveying.

Researchers from the Virginia Commonwealth University (VCU) Health System found that simply using a paper and pen during patient intake was a simple and effective strategy for identifying patients experiencing the SDOH, they reported in a recent study published in the Journal of the American Board of Family Medicine.

The researchers introduced the SDOH surveying tool in its emergency departments (EDs) as well as the VCU General Internal Medicine (GIM) inpatient services departments.

READ MORE: Lyft Launches Plan for Food Security, Social Determinants of Health

The survey, which was printed on a small card, allowed patients to check several SDOH with which they may have needed assistance in the pervious 30 days. Options included food, housing, utilities, transportation, day care, legal services, employment, education, substance abuse, safety, or domestic violence.

Patients also had the option to write in other social needs or to select no social needs. Cards were offered in both English and Spanish.

The surveying cards proved effective, the researchers found. Ninety-three percent of ED patients filled out the survey, while 76 percent of those in GIM facilities participated in the survey.

What’s more, these surveys revealed true social needs. Over 60 percent of patients reported at least one social need within the previous 30 days, with needs for food, transportation, or reliable housing access coming out as most common.


Documenting the SDOH may also become easier as a set of ICD-10 codes come to the market, allowing providers to make a clinical note and prescribe a solution when a patient experiences a social need.

Efforts from both the American Medical Association (AMA) and American Hospital Association (AHA) have resulted in promises for more ICD-10 codes that could indicate patient experience with the SDOH.

In June 2018, AHA clarified use of some of the few ICD-10 codes available for flagging SDOH. The codes – Z55 through Z56 – are a part of the ICD-10 code set but are not often used. This is likely because patient experiences with SDOH do not always come up in patient-provider communications. Instead, non-clinicians are most often made privy of these circumstances.

“As a result, most hospitals and health systems are unable to report these codes because societal and environmental conditions are routinely documented and addressed by non-physician providers, such as case managers, discharge planners, social workers and nurses,” the bulletin explains.

The June 2018 announcement asserted that non-clinicians may use these codes to document the SDOH, making it easier for clinicians themselves to flag patients who may benefit from a social service.

A separate deal between the AMA and UnitedHealthcare called for even more ICD-10 codes related to the SDOH to allow providers to flag patients.

“UnitedHealthcare and the AMA share a common goal of expanding the health care system’s perspective to consider the whole person—-not just medical care—-by placing as much emphasis on people’s social needs as on their clinical needs,” said Bill Hagan, the president of Clinical Services at UnitedHealthcare. “By working together to leverage data, technology and the incredible expertise of our network physicians, we can more effectively address the social factors that limit access to health care.”

ICD-10 codes relating to the SDOH would be entered into the medical record. From there, providers can SDOH flags and refer patients to certain community health services that would ideally address those social needs.

“The AMA is excited to work with UnitedHealthcare through the continuing efforts of our Integrated Health Model Initiative (IHMI) to foster collaboration around innovative data and technology-driven processes for incorporating social determinants of health into routine medical care,” said Tom Giannulli, Chief Medical Information Officer of AMA’s IHMI. “The collaboration reinforces the importance of social and environmental factors in patient care, and will shape IHMI’s efforts to support clinical decisions with useful and valid data to achieve broad improvements in health and greater health equity.”