Institutional Determinants of Health: Adolescent Health Crises as Sites of Social Intervention and Practical Reform

From Social, Structural, and Ecological to Institutional Determinants of Health

Attention to the social, structural, and ecological determinants of health has broadened how health professionals, policymakers, and social scientists conceive of etiology and disease mitigation through focus on the effects of discrimination, disadvantage, and toxic exposures (Braveman et al., 2011; Crear-Perry et al., 2021; Li, 2017; Schulz & Northridge, 2004). Yet, for the explanatory power that these models of health have, they are relatively inert as the basis for positive social change due to their identification of intractable forces as the basis for disease causation (Crammond & Carey, 2017; Wall et al., 2009). Efforts like “structural competency” have sought to rectify this in clinical settings but are difficult to gauge in their impact outside of the clinic (Metzl & Hansen, 2014). Institutional and interpersonal racism may be the cause of poor treatment, but how can qualitative health research support interventions that obviate the need to address individual-level interventions?

In this article, I draw attention to “institutional determinants of health” as a pragmatic framework for addressing disease causation, disability, and their mitigation through policy reform that intervenes at the institutional level. I elaborate how “mythic thinking” serves to keep institutions as they are and draw on discussions of “loose” and “tight” norms to demonstrate how interventions at the institutional level can lead to positive outcomes. By way of example, I focus on two U.S.-based cases, school start times and youth tackle football, to show how policy-level interventions can alleviate negative effects of individual-institutional interactions that result in negative health outcomes for adolescents that can have lifetime effects. Similar institutional interventions might be articulated for other individuals and communities who are affected by other institutional practices and policies that have demonstrable health effects.

School start times and youth tackle football are very different in the ways that they confront ideas about normal and desirable behaviors and the role of institutions in shaping and controlling these behaviors. They offer obvious sites for intervention in institutional arrangements and demonstrate the challenges associated with different kinds of interventions and their associated social frictions. Early school start times result in insufficient sleep for teenagers, including symptoms associated with Attention Deficit Disorder (ADD), Attention Deficit Hyperactivity Disorder (ADHD), anxiety, and depression (CAREI, 1998; Mousavi & Troxel, 2023). Youth tackle football has been shown to lead to lifetime cognitive impairments due to repeated concussions (Alosco & Stern, 2019). Policy-level interventions could have positive effects on children’s health but meet resistance in American norms and values about school start times and youth sports (McGlynn et al., 2020; Warner & Knoester, 2022; Wolf-Meyer, 2012), which are grounded in pervasive myths. In the case of school start times, these myths are based in ideas about children’s biology and the origins of the American school; in the case of youth tackle football, these myths center on possible financial outcomes for adolescent athletes. In both cases, these myths serve as impediments to the implementation of scientifically grounded institutional policies that promote well-being. In forwarding attention to the institutional determinants of health, I appeal to the need to develop interdisciplinary approaches to addressing institutional reforms that work against discriminatory institutional norms that result in disparities in health outcomes.

“Institutional determinants of health” offers an immediate site of intervention for the improvement of outcomes related to disease and disability in the everyday contexts that shape people’s lives. In focusing on institution-level outcomes, the knowledge bases of multiple stakeholders and communities can be brought together to facilitate meeting the needs of several constituencies in the immediate term and over the life course. As communities and individuals affected by specific institutional arrangements and practices, patients and clients of institutions—as well as institutional actors—can serve as sources of insight into the effects of institutional arrangements on individuals. Because patient and client communities are often rendered as non-experts, even in relation to their experiences (Epstein, 1996; Hartblay, 2020), embracing qualitative methods that provide stakeholders with the ability to articulate their concerns provides a basis for approaching institutional policies and practices from a community-focused position that has the possibility to reshape norms in line with available evidence. Across the sciences, medicine, social sciences, humanities, and arts, rallying empirical data that support policy reforms and their positive outcomes is necessary to overcome mythic cultural biases that work against the promotion of evidence-based practices. In attending to institutional determinants of health, the social, structural, and environmental determinants of health and disease become manageable as sites of policy intervention.

I approach these concerns as a medical anthropologist of American society who employs mixed-methods that draw on ethnographic participant-observation in clinics, hospitals, activist networks, schools, and workplaces, interviews with actors in these institutions, and textual and archival analysis of matters of concern that intersect with these actors and institutions. Over two decades of research on a variety of thorny medical and social problems, I have followed how social changes have not occurred, despite overwhelming scientific evidence that should support modest institutional reforms for positive outcomes for individuals and communities. Central to this inaction in the United States are a set of myths (Barthes, 1993) that Americans tell themselves to justify social organization as it currently exists, which I refer to as “mythic thinking.” Myths serve to simplify complex social problems by providing answers that appear commonsense and grounded in historical traditions that are often assumed to align with more “natural” periods of human history and social development (Hobsbawm & Ranger, 2010; Lock, 1993). In this article, my focus is on institutional interventions as an opportunity to work against entrenched forms of commonsense that are mythic and difficult to counteract at the societal level. Acting on the norms embedded in institutions offers possibilities for overcoming the inertia of myths, particularly related to health (Broom et al., 2017; Wolf-Meyer, 2015).

I first turn to a definition of “institutional determinants of health” and how theories of institutions and norms help to elaborate possibilities for reform. I then examine two health crises among American adolescents that are shaped by myths that structure social norms and institutional policies and practices. The first of these examples, school start times, has a wealth of research in support of its alteration for the benefit of adolescents; the second example, youth tackle football, is a limit case in how difficult institutional reform can be. In discussing institutional determinants through these two examples, I focus on theories of social change and how changes have been enacted through top-down and bottom-up action that can lead to institutional reforms and supplant mythic thinking. By way of conclusion, I argue that addressing institutional reforms in support of positive health outcomes demands rigorous contributions from interdisciplinary approaches that draw on strengths from across the qualitative social sciences, humanities, and arts. Susan Sawyer et al.’s (2012) call to attend to adolescent health to “improve health, both in adolescence and later in life” motivates my attention to the institutional determinants of adolescent health. Institutional reform provides a clear route toward achieving positive outcomes across the life course while also describing the problem and possibilities of institutional reforms as an agenda for qualitative health research across the social sciences, humanities, and arts.

What Are “Institutional Determinants of Health”?

“Institutional determinants of health” draws attention to the ways that the arrangements and practices of institutions shape individual and collective outcomes with negative and positive effects on health. As an intermediary focus between individual and social, structural, and ecological determinants of health, institutional determinants provide a means to inveigh through policy interventions that can alter everyday practice in ways that reflect societal, medical, and scientific priorities and lead to positive outcomes for individuals, families, and stakeholder communities. Attention to institutional determinants of health provides a mechanism to scale down the challenges of social, structural, and ecological determinants of health to actionable goals that provide evidence-informed practices that support institutional actors, caregivers, and, most importantly, those that institutions seek to serve as communities and clients. In mobilizing institutions as sites of intervention for determinants of health, I elaborate how their role as translocal bureaucracies that serve as sites of control through the naturalization of myths as facts offers opportunities for analysis and critique. I briefly survey these features—bureaucracy, naturalization, translocality, control through norms, and fact setting—as they have been approached by social scientists to offer a counterpoint to the challenges implied by structural, social, and ecological determinants.

Epidemiologists and social scientists have drawn attention to the social and structural determinants of health, seeking to point to the way that forms of discrimination provide the “root causes” of differential outcomes for patients who exist in discriminated-against categories when compared to privileged individuals and communities. Whereas the “social determinants” of health have led to vague conceptions of differential exposures that lead to poor health outcomes, for example, food deserts influencing diet-related diseases (Leatherman & Goodman, 2005), focus on structural determinants of health helps to draw attention to how food deserts exist as an effect of long-standing racist structures in property ownership that have led some communities to be chronically underserved with amenities and simultaneously exposed to particular toxic chemicals (Guthman, 2011). For example, Joia Crear-Perry and colleagues (2021) show how racism and sexism lead to negative outcomes in relation to maternal health, which explains why American Black women disproportionately experience higher mortality rates. Attention to structural determinants can lead to positive outcomes for patients, but require “upstream” interventions, for example, changing curricula in medical school to draw attention to medical racism (Green et al., 2022). The ameliorations that structural correctives offer are slow in coming and may be contested in ways that frustrate their realization, as in resistance to curriculum changes in medical school (McDonald et al., 2024). In this respect, focus on institutional policies and practices provides a more direct means to address social and structural inequities and their impacts on individuals and communities.

Institutions have been rigorously theorized since the beginnings of modern sociology, anthropology, and political theory (Castoriadis, 1998; Tournay, 2011), where questions about religion, political organization, and kinship guided interests in theorizing the social as a distinct domain of human life (Douglas, 1986; Parsons, 1951; Tarde, 1899; Weber, 1978). Institutions are simultaneously vague governing structures that organize our lives, and everyday contexts in which we raise our children, learn as students or teach as educators, work as employees, and pay taxes and vote as citizens (or work toward that outcome as immigrants); we often know an institution because it has effects on our lives and not because of its formal structure. Institutions that are bureaucratic structures have nested levels that seek to distribute agency, making it so, no one person can be held responsible for the outcomes of institutional action or inaction (Hull, 2012; Riles, 2006). All institutions are governed through policies and practices, which shape the lives of people who participate in them; this can include set working and school hours, designated lunch, break, and recess times, and guidelines for dress, behavior, and productivity, all of which carry embedded expectations about work, school, age, ability, and gender in ways that impact individuals and shape their actions. These policies and practices can be informed by mythic thinking, as in the case of school start times, whose structure is often attributed to natural rhythms but is actually grounded in decisions that set institutional policies in the 19th century (Lazerson, 1971).

Because of their ubiquity in our everyday lives, institutions are often naturalized, which places their practices beyond critique (Daston & Vidal, 2004; Yanagisako & Delaney, 1994). For example, Americans widely accept that the structure of work and school days are based on an agrarian structure of work, including the distribution of the school year over the 12-month calendar and the daily schedule of schooling (Wolf-Meyer, 2012; Zerubavel, 1985). However, evidence supports that school and work days in the United States owe their origins to the concretization of time-use by industrial labor arrangements, which placed parents into full days of work, from dawn until dusk before electrical lighting on factory floors (Roediger & Foner, 1989; Thompson, 1993), and children into school as a form of daycare (Lazerson, 1971). As discussed below, in debates about changing school start times, science about adolescent sleep needs often chafes against expectations about what time children should be at school as a set of normative beliefs that are based on mythic claims about human relationships with nature. Debates about flextime and remote work are beset by similar challenges, as mythic ideas about work time and the social role of labor influence how employers accept the possibilities of changing how labor is organized and how its organization benefits workers, their families, and their health (Kelly et al., 2008). Policies derived from norms that are based in mythic thinking govern these practices and serve as sites where attention to normative expectations of behavior interferes with positive health outcomes.

Institutions are simultaneously local and translocal. For example, children attend a school within a school district that sets district-wide policy. At the state level, school districts have additional policies set, often in accordance with federal mandates. One can expect that one’s children will have similar experiences in their schooling as peers in other schools in the same district as well as peers at other schools in the state and across the country. There are variations, often determined by county, state, and federal funding, as well as interpretations of policies by administrators, teachers, and staff. In these ways, public education in the United States is local in terms of specific institutions demarcated by classrooms, buildings, administrators, and school boards, and translocal in that the school district governs many such local institutions, with similar translocal effects at the state and federal levels. Because of this, acting on translocal institutions through policy reform at the local, state, and federal levels can serve to affect practices across diverse institutions that are subject to translocal governance, which can also allow for structured variance within a translocal institutional system, for example, schools choosing to start at earlier or later times or schools based on their having specific extramural programs (CAREI, 1998).

Institutions are sites of control (Nader, 1997), which occur through the establishment of “tight norms” as policies. In doing so, tight norms serve as the basis for making norms into normative expectations, with consequences for those who ignore or challenge them as policies (Foucault, 1995). Zoltán Farkas (2019) defines tight norms against “loose norms,” arguing that institutions find their power in the establishment of tight norms as the basis of their control of individuals and their behavior. For Farkas, loose norms play a role in our everyday interactions and provide the basis for moral decision-making: he provides the example of whether one gives up their seat on a bus to an elderly, disabled, or pregnant person, the repercussions of which are not legal, but affect one’s moral standing in society—at least to the extent that they are observed by others. Tight norms, comparatively, are indifferent to one’s standing as a person and are governed by policies, laws, and other codified rules. Farkas provides the example of whether one can ride a bus at all to draw this distinction. If one enters a bus without fare, they are unable to ride the bus. If one sneaks onto a bus without paying fare and they are discovered, they face being fined according to the policies of the service provider, which may also be a municipal government. Institutions find their powers in policing tight norms, which also shape how individuals live their everyday lives, even in the absence of directly interacting with a representative of an institution, for example, bus riders will pay their fares even to automated machines without being surveilled, thereby upholding institutional and social norms. Loose norms often lay the commonsense basis for institutional policies, which recast these loose norms as tight norms with consequences for individuals and communities, and which can only be changed through supplanting them as policies based on more convincing evidence. But this can be frustrated by the presence of mythic thinking that impedes new policies and practices from being enacted.

Relatedly, institutions buttress their powers through fact setting (MacCormick, 1998), which often ground their abilities to assert the moral validity of their exercising of control. For example, recent research employed by American schools argues that there is a direct correlation between numbers of absences and a student’s ability to succeed in their classes (Kassarnig et al., 2017); this is commonsense for many institutional actors, both inside the institution (teachers, administrators) and outside (parents, policymakers). This established fact leads to practices that seek to control students in their attendance (e.g., punishments for regularly missing school, including detention) and affects parents as well, as they are asked to monitor their children to ensure that their absences are valid, with the threat that they can be reported to other state actors, including Child Protective Services (Armfield et al., 2020), for their failures to serve as extensions of school’s institutional power. Research also shows that the students most likely to have excessive absences are those with chronic illnesses, including asthma. When physically mapped, the correlation between asthma and pollution is high, with children in urban spaces—and especially spaces that are heavily trafficked and proximate to sources of pollution—being likely to be recurrently truant (Hsu et al., 2016). The lack of success of urban, Black students confirms racist mythic thinking about their educational prospects (Merolla & Jackson, 2019), but attention to the broader context of their truancy as a result of the structural and ecological conditions of their health demonstrates how institutional fact setting obscures the forces at work that compound the students’ experiences of chronic illness, school absences, and educational achievement. In this way, the fact setting of institutions can reify norms rooted in mythic thinking as the basis of policy and control, which creates sites where interdisciplinary attention can make meaningful interventions in promoting health outcomes.

School Start Times and Youth Tackle Football as Institutional Determinants of Health

In this section, I provide two examples of institutional structures that lead to negative health outcomes for adolescents. These outcomes have immediate effects, as in the case of lost sleep and poor school performance related to early school start times, as well as long-term effects, as in the case of concussions acquired through youth sports on cognitive health in later life. My choice of these two examples is because they offer two levels of complexity and plausibility. The evidence about school start times’ impacts on students is robust and widely available; altering school start times can occur at the local level through school board adoption of new policies, which often requires only a vote on the part of school boards and the implementation of the new institutional policy through institutional actors. In these ways, the alteration of school start times is plausible but runs into challenges associated with social norms based in mythic thinking. In the example of youth tackle football, social norms are a trenchant problem, as many Americans value youth tackle football out of proportion to its benefits to their children. Even more difficult is the multi-level challenges of institutional reform, from the local to the national and across different kinds of institutions (e.g., extramural sports, school districts, university sports teams, and national sports teams and authorities). I include the youth tackle football example not because it is plausible, but as a test case to demonstrate the difficulties associated with taking an institutional-level approach to health reforms. The alterations to youth tackle football in the United States are likely implausible without widespread moral concern about the effects of the injuries on the health outcomes of children over their life course, which might serve to disrupt the mythic thinking that keeps norms in place.

Discussion

Stakeholders have been slow to adopt policy changes at the institutional level for the benefit of youth, both in their role as students and as athletes. In the comparative case of youth alcohol consumption, policy changes were enacted without robust scientific evidence of the harms of alcohol consumption, including the U.S.-wide adoption of age 21 as the legal drinking age. These changes occurred largely based on loose norms (Toomey et al., 1996) and have only recently been supported by scientific evidence. Meta-analyses of youth alcohol consumption have demonstrated the impairments of grey and white matter development in the brain, especially related to the regular consumption of alcohol to a state of drunkenness (Squeglia et al., 2015; Tapert & Eberson-Shumate, 2022). Moreover, long-term impairments in cognitive functioning have been demonstrated as related to alcohol consumption, particularly in relation to challenging tasks (Squeglia et al., 2012). There have also been indications that drinking alcohol in youth leads to impairments in attention (Tapert et al., 2002) and memory functions (Nguyen-Louie et al., 2016). In the context of attending to the institutional determinants of health, the remarkable thing about youth alcohol consumption is that there appears to be a consensus about its negative effects necessitating policies to be enacted at several institutional levels, which developed out of the adoption of loose norms barring youth alcohol consumption. Given the limitations expressed in meta-analyses conducted on available research, very few studies of merit on youth alcohol consumption have been conducted to date (de Goede et al., 2021), yet Americans acted proactively with positive results. In comparison, the data available to make claims about the effects of school start times and youth tackle football are robust. Inertia in adopting institutional reforms points to the need to address loose and tight norms that are based in mythic thinking to enact changes in expectations as they relate to institutional organization and protections for children’s well-being.

One of the questions a turn toward institutional determinants of health must face is how these changes will come about, how their adoption will be facilitated, and how their resistance will be met by those interested in promoting institutional reform for the betterment of stakeholder well-being. The imposition of institutional norms based on scientific claims runs the risk of being treated as illegitimate, either because of their status as based in “dubious” scientific claims or because of the process whereby they become the basis for institutional reform; imposition without consensus building runs the risk of increasing resistance through recourse to mythic thinking (Pierson, 2004, p. 138). In drawing attention to institutions as a site of intervention, I am interested in institutional reform as akin to what Paul Pierson (2004, p. 5) refers to as “institutional development.” This language is meant to distance these efforts from “institutional change,” which implies that institutions are the result of rational and deliberate design. Instead, “institutional development” helps to account for how institutions change over time as responses to external and internal demands and actions.

There are two immediate paths through which institutional reform can occur, top-down creation of tight norms in the form of new policies, laws, and rules, and bottom-up development of loose norms associated with moral behavior, which can lead to the eventual creation of tight norms at the institutional level (Elias, 2000). What I am suggesting here is in-between these approaches, which seeks to marry scientific and medical evidence with qualitative data regarding individual and community needs and well-being. Working with these varied data provides multiple resources to overcome mythic thinking that serves as an impediment to institutional reform. In addressing the resilience of institutions, like schools and the family, it is vital to account for the normalizing myths that ground beliefs about institutions, their origins, and their effects. The investments that individual actors have made in specific institutional arrangements and outcomes lead them to resist reforms that thwart those investments (Pierson, 2004, p. 165). Resistance to institutional development in relation to everyday institutions like schools and the family depends on individual investments at the level of myth that thereby perpetuate institutional norms not because they benefit anyone but because their perpetuation keeps norms intact.

Fundamentally, institutional reform depends on promoting new narratives that allow stakeholders to conceptualize how reforms meet their needs and the needs of other community members by overcoming mythic thinking. The intensification of “alternative facts,” misinformation, and disinformation since the turn of the 21st century has resulted in deadlocks wherein facts are met with counter-facts and their adjudication is contested, if not impossible to achieve because their rationale lies in mythic thinking (Segerståle, 1996). Interdisciplinary approaches to shared problems—in this case, institutional reform—provide narrative purchase into the history and contemporary practices of institutions, their stakeholders, and the communities they exist within. In providing a diversity of narratives, including attention to origins and consequences, institutions and their effects are denaturalized as inevitable or necessary and instead situated as contingent and the result of decisions made by actors over time, including in the present. Whether or not this awareness leads to interventions in institutional arrangements and support for interventions is impossible to predict; but attention to the social and historical context of institutions and their broad impacts on their stakeholders and communities create the condition for the development of new loose and tight norms in support of institutional reform that work against deeply entrenched mythic thinking.

Conclusion

Qualitative health research emphasizes the subjective experiences of patients and clients to demonstrate how illness, disability, and other embodied experiences are shaped by and shape health care provision and outcomes. These subjective experiences are shaped by institutions, both in the moment of interaction between patient or client and health care provider and in the long trajectory of institutional interactions that individuals have in the development of their subjectivity over a life course (Rhodes, 1991). Far from being inert containers for everyday interactions, institutions provide the normative frameworks through which individuals come to understand themselves and their experiences (Foucault, 2000). Focusing on the subjective experiences of individuals alone misses the roles that institutions and their enactment of norms through myths promulgate to produce positive feedback loops that entrench beliefs and practices as the basis of institutional action. Qualitative health research needs to address institutions, institutional actors, and the forms of institutional development and resilience that are possible for the purpose of improving individual and societal health outcomes outside of the limitations that mythic thinking imposes on institutional reform. Addressing these institutional impediments requires embracing interdisciplinary approaches that describe how institutions and individuals create feedback loops through mythic thinking that render some developments possible and others improbable.

How institutions affect the health of those that interact with them is often obscure, even to institutional actors, who may accept facts because they reflect commonsense understandings based in mythic thinking rather than being based in robust empirical evidence, as with school start times. To unsettle this mythic thinking, new narratives need to replace old ones. Historians are trained in genealogical approaches that enable them to demonstrate how commonsense ideas have become the basis for facts, as well as providing them with the skills to contextualize the enactment of tight norms, including policies, laws, and rules, and their consequences (Roediger & Foner, 1989; Stern, 2005). Ethnographers demonstrate the lived experiences of institutionalized facts and tight norms, and offer symmetrical analyses of the stakeholders who interact with institutions, including clients and institutional actors (Jenkins & Csordas, 2020; Myers, 2015; Rhodes, 1986). Attention to subjective experiences grounds arts- and humanities-based approaches, which draw on expressive culture to demonstrate the sometimes ineffable effects of loose and tight norms on institutional stakeholders, as well as the commonsense forms that mythic thinking can take (Berlant, 2011; Sedgewick & Frank, 1995). When paired with the approaches in the laboratory sciences and quantitative social sciences, these approaches to qualitative health research add a critical lens on the creation and mobilization of institutionalized practices and policies as they lay the basis for tight norms, their enforcement, and effects. Situating institutions as the focus to draw these approaches together provides a framework for intervening in institutions to advance the outcomes associated with approaches to structural, social, and ecological determinants of health.

Qualitative health research that spans the arts, humanities, social sciences, and laboratory sciences provides a robust means to describe the historical development, contemporary effects, and institutional logics of mythic thinking as the basis of tight and loose norms. In providing these historical and contemporary descriptions, opportunities for situated corrections occur: being able to demonstrate to stakeholders when a policy, rule, or law was implemented provides a context which they may recognize as being invalid given contemporary concerns, as in the agricultural basis for American schooling. In this way, a new narrative might work to supplant an older one that has outlived its usefulness. Similarly, being able to demonstrate the impacts of a tight norm on stakeholders in a symmetrical fashion, for example, school start times affect not only students, but their parents, their teachers, school administrators and staff, and their broader community, helps to describe the costs and benefits of any given institutional arrangement and provides a broader narrative for considering institutional reform. Cutting through the mythic thinking associated with loose and tight norms is a benefit of a diverse, interdisciplinary approach that can describe the many factors that have shaped and continue to shape institutions, their policies, and their effects on individuals and communities. Moreover, robust, interdisciplinary narratives that draw from multiple empirical traditions may also work to curtail criticisms of the imposition of new tight norms through recourse to counter-narratives of history and experience that promote more inclusive and diverse ways of understanding individual experiences and institutional histories.