Bringing Health to Life: An Institutional Ethnography of the Social Determinants of Health Framework in a Maternal and Child Health Setting

Health inequities, or avoidable and unjust differences in health status across groups, are/nwidely considered public health and social problems. Maternal and child health (MCH)/ninequities, such as those in maternal and infant mortality, low birthweight, or preterm birth, are/nsome of the most enduring and marked inequities in the US. Given the way that MCH outcomes/nare used as a metric to understand the functionality of a health and social service system overall,/nthese inequities point to deep-seated structural issues in US healthcare. Additionally, a growing/nbody of literature demonstrates that more than genetics, individual behavior, or even quality of/nmedical care, it is the social determinants—the conditions in which we live, learn, work, play,/nand age—that determine MCH and other health inequities. Despite this growing/nacknowledgment, little is known about the role and experiences of frontline health and social/nservice workers who are charged with applying this knowledge in day-to-day practice. Moreover,/nlittle is known about how such frontline workers are shaping this knowledge when it “hits the/nstreets.”/nThis dissertation analyzes the enactment of the social determinants of health (SDOH)/nframework, or the public health framework that outlines the role of upstream factors in/ndetermining health outcomes. To do so, I conducted an institutional ethnography of frontline/nhealth and social service workers charged with addressing racial, ethnic, and economic MCH/ninequities. My field site is a mid-size (approximately 90 employees) non-profit providing a range/nof MCH services in a large, West Coast City where health inequities reflect the broader MCH/ninequities in the US. I sought to uncover what the everyday routines, experiences, and practice/ndilemmas of this workforce could reveal about tackling MCH inequities and implementing the/nSDOH framework., This work employed discourse analysis of agency documents, participant/nobservation, and semi-structured, in-depth interviews throughout a nine-month period of/nfieldwork. Data were analyzed using a grounded theory as well as directed and conventional/ncontent analysis approach to coding and theme development. Analysis was informed by streetlevel/nbureaucracy theory and a materialist and structuralist approach to the production and/namelioration of MCH inequities./nSeveral primary findings emerged from this study. First, I explore interprofessional/ncollaboration as it relates to enacting and animating the SDOH framework. I find that the/nfrontline workforce relies on three key types of collaboration to bring the SDOH to life: within/nagency collaboration and role-blurring, collaboration with a safety-net hospital, and common/ncause, or the engagement in a shared analysis and framework for political action. Next, I explore/nthe impact of prevailing social norms on implementation of the SDOH framework. Specifically, I/nconsider how definitions of the private, heteronormative, nuclear family emerge in a health and/nsocial service setting. I find that frontline workers negotiate the legacy of problematic and often/ncontradictory health and social service policies regarding who constitutes a family and when/nduring pregnancy a family is understood to exist. Finally, I explore a continuum of frontline/nprovider perspectives regarding the SDOH framework and health inequities. I consider provider/nengagement with the SDOH framework through the lens of sociologist C. Wright Mills’/n“sociological imagination,” or the ability to understand one’s actions and circumstances as part/nof broad, historically-contingent social forces. I understand engagement with the SDOH/nframework to exist on a continuum from apathy and burnout to possessing a sociological/nimagination, and, finally, to structural competency, or the trained ability to analyze and intervene/nupon the upstream factors that produce health inequities./nEnacting the SDOH framework in MCH and other settings is an important part of/naddressing health inequities and ultimately, ameliorating social disadvantage. The SDOH/nframework informs the development of an emerging SDOH workforce, or a network of health/nand social service professionals who are integrating practice systems and institutional resources/nto adequately meet social as well as physical health needs and ultimately, address health/ninequities and social disadvantage. Studying frontline SDOH-related work from the vantage/npoint of those with the most intimate experiences of service delivery, I investigate up close the/nrole of health and social services in integrating social and clinical care. Additionally, this/nworkforce is shaping SDOH knowledge and practice with their daily decisions and strategies to/nmeet client need. I conclude that strategies to combat health inequities must be understood in/nterms of frontline workers’ lived experiences and perspectives for meaningful and impactful/npractice change to occur.

Advisor: Gomez, Anu M