Clarifying the social and structural determinants of health and health inequities: refining and extending a conceptual framework

Social and structural determinants of health and health inequities (SSDHHI) include upstream factors influencing policies that shape health. We conducted a qualitative case study of the 2023 passage of the Minnesota Child Tax Credit (CTC) to refine and extend an SSDHHI framework [Karatekin et al. (Re-politicizing the WHO's social determinants of health framework. Health Promot Int 2024;39:daae122)] that centers power and the agents who use power to shape SSDHHI. We coded interviews with key players in the state administration, legislature, and advocacy organizations (N = 15); and related news items and hearings. We operationalized the framework's components, including "Agents, Power, Governance, and Institutional Practices," the "Election System," and "Ideas" fueling narratives about the CTC. Using the results, we refined the framework by linking "Agents" and "Power"; considering the types, dimensions, and motivations for "Power"; pointing out components that need further clarification; and introducing bidirectional links between components. We extended the framework by including a temporal dimension to highlight historical roots and emphasizing the importance of the conjunctions of factors that affect SSDHHI. This framework can be used to analyze other SSDHHI and to guide action by practitioners, e.g., by identifying individual or institutional targets of interventions and strategies for obtaining and using "Power" to drive policy change and improve public health.