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.

backgroundU.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.

methodsWe 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.

resultsEquity-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.

conclusionsResponsibility 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.