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, arewidely considered public health and social problems. Maternal and child health (MCH)inequities, such as those in maternal and infant mortality, low birthweight, or preterm birth, aresome of the most enduring and marked inequities in the US. Given the way that MCH outcomesare used as a metric to understand the functionality of a health and social service system overall,these inequities point to deep-seated structural issues in US healthcare. Additionally, a growingbody of literature demonstrates that more than genetics, individual behavior, or even quality ofmedical care, it is the social determinants—the conditions in which we live, learn, work, play,and age—that determine MCH and other health inequities. Despite this growingacknowledgment, little is known about the role and experiences of frontline health and socialservice workers who are charged with applying this knowledge in day-to-day practice. Moreover,little is known about how such frontline workers are shaping this knowledge when it “hits thestreets.”This dissertation analyzes the enactment of the social determinants of health (SDOH)framework, or the public health framework that outlines the role of upstream factors indetermining health outcomes. To do so, I conducted an institutional ethnography of frontlinehealth and social service workers charged with addressing racial, ethnic, and economic MCHinequities. My field site is a mid-size (approximately 90 employees) non-profit providing a rangeof MCH services in a large, West Coast City where health inequities reflect the broader MCHinequities in the US. I sought to uncover what the everyday routines, experiences, and practicedilemmas of this workforce could reveal about tackling MCH inequities and implementing theSDOH framework., This work employed discourse analysis of agency documents, participantobservation, and semi-structured, in-depth interviews throughout a nine-month period offieldwork. Data were analyzed using a grounded theory as well as directed and conventionalcontent analysis approach to coding and theme development. Analysis was informed by streetlevelbureaucracy theory and a materialist and structuralist approach to the production andamelioration of MCH inequities.Several primary findings emerged from this study. First, I explore interprofessionalcollaboration as it relates to enacting and animating the SDOH framework. I find that thefrontline workforce relies on three key types of collaboration to bring the SDOH to life: withinagency collaboration and role-blurring, collaboration with a safety-net hospital, and commoncause, or the engagement in a shared analysis and framework for political action. Next, I explorethe impact of prevailing social norms on implementation of the SDOH framework. Specifically, Iconsider how definitions of the private, heteronormative, nuclear family emerge in a health andsocial service setting. I find that frontline workers negotiate the legacy of problematic and oftencontradictory health and social service policies regarding who constitutes a family and whenduring pregnancy a family is understood to exist. Finally, I explore a continuum of frontlineprovider perspectives regarding the SDOH framework and health inequities. I consider providerengagement with the SDOH framework through the lens of sociologist C. Wright Mills’“sociological imagination,” or the ability to understand one’s actions and circumstances as partof broad, historically-contingent social forces. I understand engagement with the SDOHframework to exist on a continuum from apathy and burnout to possessing a sociologicalimagination, and, finally, to structural competency, or the trained ability to analyze and interveneupon the upstream factors that produce health inequities.Enacting the SDOH framework in MCH and other settings is an important part ofaddressing health inequities and ultimately, ameliorating social disadvantage. The SDOHframework informs the development of an emerging SDOH workforce, or a network of healthand social service professionals who are integrating practice systems and institutional resourcesto adequately meet social as well as physical health needs and ultimately, address healthinequities and social disadvantage. Studying frontline SDOH-related work from the vantagepoint of those with the most intimate experiences of service delivery, I investigate up close therole of health and social services in integrating social and clinical care. Additionally, thisworkforce is shaping SDOH knowledge and practice with their daily decisions and strategies tomeet client need. I conclude that strategies to combat health inequities must be understood interms of frontline workers’ lived experiences and perspectives for meaningful and impactfulpractice change to occur