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

  • Author(s): Downey, Margaret Mary Bissember
  • Advisor(s): Gomez, Anu M
  • et al.
Abstract

Health inequities, or avoidable and unjust differences in health status across groups, are

widely 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, are

some of the most enduring and marked inequities in the US. Given the way that MCH outcomes

are 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 growing

body of literature demonstrates that more than genetics, individual behavior, or even quality of

medical 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 growing

acknowledgment, little is known about the role and experiences of frontline health and social

service 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 the

streets.”

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 in

determining health outcomes. To do so, I conducted an institutional ethnography of frontline

health and social service workers charged with addressing racial, ethnic, and economic MCH

inequities. My field site is a mid-size (approximately 90 employees) non-profit providing a range

of MCH services in a large, West Coast City where health inequities reflect the broader MCH

inequities in the US. I sought to uncover what the everyday routines, experiences, and practice

dilemmas of this workforce could reveal about tackling MCH inequities and implementing the

SDOH framework., This work employed discourse analysis of agency documents, participant

observation, and semi-structured, in-depth interviews throughout a nine-month period of

fieldwork. Data were analyzed using a grounded theory as well as directed and conventional

content analysis approach to coding and theme development. Analysis was informed by streetlevel

bureaucracy theory and a materialist and structuralist approach to the production and

amelioration of MCH inequities.

Several primary findings emerged from this study. First, I explore interprofessional

collaboration as it relates to enacting and animating the SDOH framework. I find that the

frontline workforce relies on three key types of collaboration to bring the SDOH to life: within

agency collaboration and role-blurring, collaboration with a safety-net hospital, and common

cause, or the engagement in a shared analysis and framework for political action. Next, I explore

the impact of prevailing social norms on implementation of the SDOH framework. Specifically, I

consider how definitions of the private, heteronormative, nuclear family emerge in a health and

social service setting. I find that frontline workers negotiate the legacy of problematic and often

contradictory health and social service policies regarding who constitutes a family and when

during pregnancy a family is understood to exist. Finally, I explore a continuum of frontline

provider perspectives regarding the SDOH framework and health inequities. I consider provider

engagement 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 part

of broad, historically-contingent social forces. I understand engagement with the SDOH

framework to exist on a continuum from apathy and burnout to possessing a sociological

imagination, and, finally, to structural competency, or the trained ability to analyze and intervene

upon the upstream factors that produce health inequities.

Enacting the SDOH framework in MCH and other settings is an important part of

addressing health inequities and ultimately, ameliorating social disadvantage. The SDOH

framework informs the development of an emerging SDOH workforce, or a network of health

and social service professionals who are integrating practice systems and institutional resources

to adequately meet social as well as physical health needs and ultimately, address health

inequities and social disadvantage. Studying frontline SDOH-related work from the vantage

point of those with the most intimate experiences of service delivery, I investigate up close the

role of health and social services in integrating social and clinical care. Additionally, this

workforce is shaping SDOH knowledge and practice with their daily decisions and strategies to

meet client need. I conclude that strategies to combat health inequities must be understood in

terms of frontline workers’ lived experiences and perspectives for meaningful and impactful

practice change to occur.

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