Association for Public Policy Analysis & Management

There is a growing appreciation among researchers that the social determinants of health (SDH) constitute a “wicked” problem; one that is subject to feedback loops, dynamic network effects, and emergent tendencies. While it is necessary to empirically establish causal relationships between specific determinants and health outcomes, traditional quantitative methods have studied reductionist, linear associations rather than considering “complex adaptive system” paradigms. Academic discussion is trending in this direction, but very few studies to date have applied a systems approach to SDH. This is likely because a systems perspective does not map neatly onto the upstream-downstream dichotomy which dominates much of the SDH literature.

Policy problem

One major difficulty policy researchers face when tackling complex social problems is establishing system boundaries that make research feasible without being reductionist. To support effective policy-making, systems research must be both comprehensive and comprehensible.

In this paper, I propose one resolution to this problem: a focus on the household as a system. The household provides a bounded environment that is both complex and measurable – the subject of feedback mechanisms and emergent behaviors, but also adhering to an observable set of needs, decisions, and outcomes. It is a system both chaotic and familiar. This paper will first explore the conceptualization of the household as a system, and then use data from a novel household-based intervention to analyze its application and generate policy recommendations.

Research questions

1. How can the complexity of SDH be captured and visualized within a household system?
2. Does a holistic, household-based intervention improve health and multi-dimensional resilience?

Methods

First, I visualize the household as a complex system using common systems thinking methods, including rich pictures and causal loop diagrams. Second, I present preliminary results from a quantitative analysis of NeighborhoodHELP – a household-based intervention operating in low-income and immigrant communities in Miami-Dade County, Florida. NeighborhoodHELP has conducted bi-monthly household visits over a period of over two and a half years (March 2015 through December 2017) to over 800 households. The longitudinal data includes households’ self-reported “most urgent” social need, services provided by outreach workers, and a “risk score” rating (from 1 to 5) across ten different SDH sectors: health, food security, housing, income, employment, education, transportation, daily activities, technology, and legal support.