UC Berkeley

In any given community, there are multiple organizations and sectors – including health care, public health, education, and social services – that have a hand in addressing health, as well as the social and economic determinants of health. Often, these sectors are siloed and not coordinating as well as they could be. This dissertation examines organizational changes within different sectors that can support linkage and collaboration across sectors. The first study examines what area characteristics promote the establishment of school-based health centers (SBHCs), which are a key way to increase access to health care for children who are most in need. Findings showed that the availability of nearby community health centers, as well as the existence of a SBHC state advocacy organization, supported the establishment of SBHCs. These results point to the need for extra financial and technical support for school districts in counties that have few or no community health centers. The second study examines multilevel organizational influences of physician practices’ screening for social risks, a care delivery innovation recommended to mitigate disparities, and a key step for preparing health care systems to engage in relationships with relevant community organizations in service of addressing identified needs. Increasingly, physician practices are being acquired by health systems. This study examines how system versus practice characteristics influence whether practices implement screening for social risks, with the goal being to understand what organizational level of intervention may be most effective for increasing screening for social risks. We found that practice-level characteristics explained more of the variance in a practice's screening for social risks, which suggests that efforts to expand social risk screening among system-owned practices should focus on strategies at the practice level, such as increasing technology capacity and patient engagement strategies. The third study tests an approach for identifying US counties with better-than-expected child health outcomes, also known as positive deviants. This study provides the first step – identification of positive deviant counties – that future qualitative research can build on to understand community activities, including multi-sector collaboration and linkages, that contribute to exceptional child health outcomes.