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

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Learn more: PMC Disclaimer | PMC Copyright Notice Health Promot Int . 2026 May 29;41(3):daag072. doi: 10.1093/heapro/daag072 Clarifying the social and structural determinants of health and health inequities: refining and extending a conceptual framework Canan Karatekin 1, ✉ , Shruti Chakraborty 2 , Maya Fteiha 3 , Frederique Corcoran 4 , Unnati Khanna 5 , Susan Marshall Mason 6 , Andrew J Barnes 7 Author information Article notes Copyright and License information 1 Institute of Child Development, University of Minnesota, 51 E. River Road, Minneapolis, MN 55455, United States 2 Department of Applied Psychology, University of Delhi, Benito Juarez Marg, South Campus, South Moti Bagh, New Delhi 110021, India 3 Institute of Child Development, University of Minnesota, 51 E. River Road, Minneapolis, MN 55455, United States 4 Institute of Child Development, University of Minnesota, 51 E. River Road, Minneapolis, MN 55455, United States 5 Department of Psychology, School of Psychological Sciences, Christ (Deemed to be University) Delhi NCR, Nandgram Rd, Marium Nagar, Sewa Nagar, Ghaziabad, Uttar Pradesh 201003, India 6 Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, 1300 S. 2nd St., Room 300 West Bank Office Building, Minneapolis, MN 55454, United States 7 Department of Pediatrics, Medical School, University of Minnesota, 2025 E. River Parkway, Minneapolis, MN 55455, United States ✉ Corresponding author. Institute of Child Development, University of Minnesota, 51 E. River Road, Minneapolis, MN 55455, USA. E-mail: karat004@umn.edu Roles Canan Karatekin : Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Supervision, Writing - original draft, Writing - review & editing Shruti Chakraborty : Formal analysis, Investigation, Methodology, Visualization, Writing - original draft, Writing - review & editing Maya Fteiha : Formal analysis, Visualization, Writing - original draft, Writing - review & editing Frederique Corcoran : Conceptualization, Formal analysis, Investigation, Methodology, Writing - original draft, Writing - review & editing Unnati Khanna : Conceptualization, Investigation, Methodology, Visualization, Writing - review & editing Susan Marshall Mason : Conceptualization, Writing - review & editing Andrew J Barnes : Conceptualization, Writing - review & editing Collection date 2026 Jun. © The Author(s) 2026. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License ( https://creativecommons.org/licenses/by-nc/4.0/ ), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com. PMC Copyright notice PMCID: PMC13221698  PMID: 42216839 Abstract 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. Keywords: social and structural determinants of health and health inequities, child tax credit, qualitative research, case study Contribution to Health Promotion. Tested a framework on social and structural determinants of health and health inequities (SSDHHI) that centers power and the agents who use that power to shape population health. Conducted a qualitative case study of the 2023 passage of the Minnesota Child Tax Credit to accomplish the aims. Revised and extended the framework and operationalized the constructs. The framework centers power and agents, missing in some other SSDHHI frameworks, and can be used to analyze other factors influencing public health and guide action. Who and what influences public health? When an infant dies, e.g. what is the chain of responsibility? Or when a child grows up without being abused, who is to be congratulated? It is often the parents, the most immediate and visible proximal agents, who are blamed or credited, with emphasis on interventions with parents. Yet, these individual interventions, especially those that require substantial parental effort and motivation, are typically not scalable and thus ineffective for improving public health ( Frieden 2010 ). On the other hand, the consequences of broader societal structures affecting children’s wellbeing (e.g. livable wages; access to quality health care, housing, and schools) are less visible, so they tend to be relatively overlooked. Shifting and reforming these structures has greater potential for improving the lives of more children, but because of their relative invisibility, they are underemphasized as intervention targets ( Frieden 2010 ). A growing body of research demonstrates the potential for specific institutions and systems (e.g. health care, child welfare) to improve child health. There are fewer investigations of the agents (e.g. politicians, corporations) who create and enforce the institutional rules and regulations. Understanding how institutions and systems can be changed is crucial for actualizing their potential health impacts. Existing frameworks for conceptualizing upstream determinants of children’s health ( Bronfenbrenner 1979 , Solar and Irwin 2010 ) are limited in several ways. They tend to be vague, especially at upstream levels. Therefore, they do not provide enough guidance for identifying agents responsible for decisions impacting population health, how agents use their power, and how they can be challenged or supported. This knowledge is critical for guiding public health interventions on the foundational structures affecting health and health equity. Other frameworks are limited by a focus on single upstream determinants (e.g. corporations, economics, or legal structures), although upstream determinants are interconnected. Moreover, as noted by Karatekin and colleagues (2024) , some frameworks for social determinants of health (SDH) have been distorted and misinterpreted, and the political roots of determinants have been de-emphasized, partly because the frameworks are not well specified. Thus, there is a need for conceptual frameworks about social and structural determinants of health and health inequities (SSDHHI) that are broad enough to include interacting determinants at upstream levels but detailed and operationalizable enough to be useful for conceptualizing and studying SSDHHI and guiding action to improve them. When examining the effects of laws and policies, public health researchers often study their health impacts. Although identifying policy effects on health outcomes supports the evidence base for SSDHHI, equally important for replicating positive policy impacts is evidence identifying how and why policies came about in the first place, who played key roles, how they did or did not use their power, and what kinds of structural determinants (e.g. broad economic systems; values and worldviews; governance and institutional practices; election systems; other laws and policies) hindered or facilitated their passage. As Navarro (2009) noted, the World Health Organization (WHO) Commission’s SDH framework’s “studious avoidance of the category of power (class power, as well as gender, race, and national power) and how power is produced and reproduced in political institutions is the greatest weakness of the report. It reproduces a widely held practice in international agencies that speaks of policies without touching on politics… It is profoundly apolitical, and therein lies the weakness of the report” (p. 15). Navarro ( 2009 , 2021 ) and others ( Krieger 2001 ) have paid more attention to power dynamics and the challenges of studying structural determinants in a scientific manner ( Krieger 2012 ). To address the need for more explicit conceptualization of the role of agents and power in SSDHHI frameworks, we developed an agent- and power-centered SSDHHI framework ( Karatekin et al . 2024 ). Our original framework ( Supplementary Figure S1 ) extends the WHO framework by identifying and elaborating on SSDHHI. However, it also explicitly includes agents who influence these structural determinants and how they use their power, based on the ideas of Heller and colleagues (2024) and others who proposed power taxonomies ( Moon 2019 , Harris et al . 2020 , Friel et al . 2021 , Popay et al . 2021 , National Collaborating Centre for Determinants of Health 2023 ). The purpose of this study was to test the utility of our framework by using it to identify key components of success in the passage of the state child tax credit (CTC) in Minnesota in 2023. We also used this case study to identify strengths and weaknesses in the framework and revise it to increase its usefulness. The Minnesota state CTC was an important improvement in support for Minnesota families that filled gaps left by the federal CTC, a partially refundable tax credit for working parents. However, as Goldin and Michelmore (2022) noted, “the vast majority of those in the bottom decile of the national adjusted gross income … distribution are completely ineligible for the [federal] CTC, and the majority of children in the bottom 30 percent of the distribution are eligible only for a partial credit” (p. 124). The Minnesota CTC is arguably the best state CTC in the USA to fill this gap. We focused on the passage of this law to test our framework because of its scale and potential positive impacts on child health. An in-depth qualitative case study of its passage is presented in another paper (to be submitted) and summarized in Supplementary Table S1 . Briefly, we found that a convergence of historical events, the concerted effort of key players and their skillful use of power, and key structural determinants in state government facilitated its notably rapid passage in 2023. In this paper, we refine and extend our agent- and power-centered SSDHHI framework ( Karatekin et al . 2024 ) as a tool for conceptualizing upstream factors that influence population health by reflecting on our experience with conducting this intensive case study of the Minnesota CTC. We focus on “Agents, Power,” and “Structural Determinants,” rather than the “Structural Stratifiers” (e.g. income, race, gender) and “Intermediary Determinants of Health” (e.g. housing conditions, behavioral and psychosocial factors) described in the WHO framework, because these are easier to operationalize and are already more comprehensively addressed in the research literature. For example, the National Institutes of Health (NIH)-supported PhenX (consensus measures for Phenotypes and eXposures) Toolkit includes a variety of measures for “Stratifiers” and “Intermediary Determinants,” but not for “Structural Determinants” ( PhenX Toolkit: Domains n.d .). Our focus is not on the impact of the CTC, but the process of applying the framework to test its applicability to real-world analysis of policies and laws that impact public health. Our aims were to refine and extend our framework. To refine our framework, we described its operationalization using well-established criteria for qualitative research ( Braun and Clarke 2006 , 2012 ) and determined which components could be coded reliably. We used insights from this process to clarify definitions and combine conceptually overlapping components. To extend our framework, we identified factors relevant to telling the story of the passage of the state CTC that could not be accommodated within the previous version ( Karatekin et al . 2024 ). We also used quantitative results to illustrate the importance of these factors. Materials and method Summary of the case study We used the passage of the Minnesota CTC as a case study to test our agent- and power-centered SSDHHI framework’s ( Karatekin et al . 2024 ) applicability. The study involved qualitative analysis of interviews with key players involved in the law’s passage (15 interviews with 16 individuals), along with analysis of publicly available legislative hearings and news articles on the law. Supplementary Table S2 has a list of the interview questions. We used content analysis to identify the “Agents” and types of “Power” that influenced the law’s passage, the SSDHHI that shaped it, and the historical and contextual factors that catalyzed it. Thematic analysis further identified worldviews and public narratives that shaped the law’s passage. We summarized the findings in Supplementary Table S1 and described the story of the passage of the law in another manuscript. Overview of the procedure To refine and extend our framework, we operationalized the broad categories (“Agents, Power,” and “Structural Determinants”) situated upstream of stratifiers in the WHO’s SDH framework ( Solar and Irwin 2010 ) and applied them to interviews, legislative materials, and news items ( Table 1 ). Table 1. Components of the agent- and power-centered SSDHHI framework. Components Definition Agents The people Moneyed interests Actors on the global stage Governments Political parties Knowledge creators Media Religious institutions Other “Agents” that may be relevant in other contexts Power Consider, e.g. What power is used for Types of power (systemic, economic/financial, structural/institutional, networking/lobbying, discursive/ideational, expert, and moral power; power of Lived “Experience”; power of personal attributes; physical force) Dimensions of power (e.g. visible/invisible, direct/indirect, exercise/impact, legality) Spaces in which power is exercised Levels at which power is exercised (e.g. state, federal) See Harris et al . (2020) and ( National Collaborating Centre for Determinants of Health. 2023 ) for more on how to think about “Power.” Structural Determinants of Health and Health Inequities “Broad geopolitical, sociopolitical, and economic systems” (please see Karatekin et al . 2024 , p. 6, for a discussion of the terms “system,” “structural determinants,” and “context”; As noted there, “System” emphasizes ordered relationships among components… “Context” is more vague and does not focus on ordered relationships… Structural determinants are conceived of as mechanisms or rules affecting inequities and operating within systems’). Political systems within countries (e.g. democracy, authoritarianism, oligarchy) Economic systems (e.g. capitalism, neoliberalism, socialism) Geopolitical configurations, such as blocs and alliances (e.g. NAFTA, NATO) “Ideas” Cultural norms, beliefs, and values (e.g. racism; sexism; ableism) Dominant narratives (e.g. health is an individual responsibility; small government is good) Worldviews (e.g. religions) Ideologies (e.g. social Darwinism, Manifest Destiny) “Governance” How different governance responsibilities are structured across agencies and levels, and which powers are included in what (e.g. the US Constitution and the Bill of Rights; colonialism) To what extent does the structure of governance protect the fundamental human right to health? Whom does it empower and whom does it disempower? “Institutional practices” To what extent does the institution and its practices protect the fundamental human right to health? Whom do they empower and whom do they disempower? Agenda setting—who sets the agenda, how, and when Decision-making—who makes the decisions and how, openness to inputs Funding Representativeness Fairness (in procedures and outcomes) Transparency Accessibility Accountability Resources Data collection and accessibility Conflicts of interest and other measures to prevent corruption Handling of intra- and inter-institutional conflicts Culture of the institution “Laws, policies, regulations, budgets, and resulting services and recommendations/guidelines” To what extent do these protect the fundamental human right to health? Whom do they empower and whom do they disempower? “Elections” Laws and policies governing elections (e.g. majoritarian versus proportionate representation systems; winner-take-all versus ranked choice voting; Electoral College; redistricting principles; who is eligible to run for office; timing of elections; who and what is allowed to be on the ballot; who is eligible to vote) Administration of elections and implementation of election laws (e.g. accessibility of voting) Election campaigns (e.g. who decides to/is encouraged to run for office; resources and funding of campaigns; media coverage of campaigns) “Implementation, interpretation, enforcement, monitoring, & evaluation of the above” Implementation Extent to which there is room for interpretation in implementation of decisions (e.g. state requirements for eligibility for safety net benefits) Extent to which laws are used for purposes for which they were intended Efficiency of implementation Awareness of affected individuals about the laws and policies Oversight and monitoring of implementation Monitoring and evaluation Are the effects of laws and policies monitored and evaluated? By whom? What kind of data are being collected? How are they analyzed? How are results disseminated? Interpretation and enforcement Which laws and policies are enforced? Costs versus benefits of breaking laws Who interprets the laws and policies? Courts and other venues for settling legal disputes The timing of court decisions Law enforcement agencies and officials (Department of Justice, attorneys general, police departments) Corrections system; public versus private prisons; prison labor Stratifiers As described by the WHO (e.g. socioeconomic status, race, gender, disability status) Intermediary Determinants of Health As described by the WHO (e.g. material circumstances; behavioral, biological, psychosocial factors) Open in a new tab We then assessed inter-coder reliability and refined the codes iteratively. The process illustrated how a broad conceptual framework can be translated into practice in policy research. We also identified factors that could not be accommodated within the original framework and suggested an extension of the framework to understand how policies shape public health. Development of the codes and the establishing reliability Qualitative data were gathered from news articles, legislative hearings, and semi-structured interviews. Interviewees were identified using purposive sampling based on our review of news articles, followed by snowball sampling during the interview process to identify additional key “Agents.” Interviews continued until no new key “Agents” were mentioned and no substantively new themes emerged, indicating that data saturation was reached. Data were stored and analyzed using Dedoose 7.0.23 ( SocioCultural Research Consultants, LLC. 2025 ). The University of Minnesota Institutional Review Board determined the study to be ‘Not Human Research’ (STUDY00023704). The coding process was iterative. A set of initial codes based on our framework was developed and pilot-tested on news articles about the federal CTC and two interviews with key players involved with other Minnesota laws. Next, we developed a codebook, which was further pilot-tested to establish inter-rater reliability. Nine main codes were developed: two representing “Agents” and “Power,” five capturing “Structural Determinants of Health and Health Inequities (Ideas, Governance/Institutional Processes, Election System, The Law, Implementation/Evaluation of the Law),” one reflecting “Historical/Contextual Factors” that influenced the state CTC’s passage, and one addressing “The Future of the State CTC” (based on interview responses). Four codes (“Agents, Power, Ideas, and The Law”) included subcodes. The final codebook included 45 subcodes spread across nine main codes. A detailed description of the codes and their subcodes is in Supplementary Table S3 . Coders were a faculty member (first author); a Developmental Psychology PhD student (fourth co-author); five Developmental Psychology undergraduates; and two post-baccalaureate research assistants with Psychology degrees (second and fifth co-authors). To pilot-test the codebook, we used the Training Center feature in Dedoose. Twenty-three training tests created by the first author were taken by the coders. Initially, coding reliability was uneven across codes. We interpreted this as a signal to revise the codebook and as data in itself–i.e. some of the framework’s components were not defined clearly. The first author met regularly with coders to discuss discrepancies and refine and modify the codebook to increase clarity until the first author and each coder reached a Cohen’s kappa ( Cohen 1960 ) of 0.70 for each code, indicating acceptable agreement ( Landis and Koch 1977 , McHugh 2012 ). Prior to finalizing the codebook and initiating independent coding, team members blind-coded 10 news articles and met to address discrepancies. Once reliability was established, each coder independently coded the news articles, legislative hearings, and interviews. Results Results reflect insights gained from applying our agent- and power-centered SSDHHI framework to empirical data. Specifically, we operationalized, tested, refined, and extended the framework through coding the narrative of the Minnesota CTC. Supplementary Table S4 shows the percentage of interviews, hearings, and news items in which each code and subcode was mentioned at least once, and summarizes how the Minnesota CTC was passed. Figure 1 shows the revised framework. Figure 1. Open in a new tab “Agents” include: the people, moneyed interests, actors on the global stage, governments, political parties, knowledge creators, the media, and religious institutions. “Power” can be analyzed, e.g. in terms of what it is used for; types and dimensions of “Power”; and spaces and levels at which it is exercised. “Structural determinants of health and health inequities” include the overarching components of (i) the “broad geopolitical, sociopolitical, and economic systems,” and (ii) “Ideas.” Underneath these, other “Structural Determinants include Governance; Institutional Practices; Laws, policies, regulations, budgets, and resulting services and recommendations/guidelines and their implementation, interpretation, enforcement, monitoring, and evaluation”; and “Elections. Stratifiers” are similar to those in the WHO framework ( Solar and Irwin 2010 ) and include social class; gender and lesbian-gay-bisexual-transsexual-queer (LGBTQ) status; race, ethnicity, culture, and religion; geographic location; disability status. “Intermediary determinants of health” are based on the WHO framework and include: material circumstances (e.g. housing, neighborhood conditions); behavioral and biological factors (e.g. health-risk and health-promotive behaviors); psychosocial factors (e.g. family and individual psychosocial characteristics, adverse childhood experiences). Aim 1: refinement and revision of the agent- and power-centered social and structural determinants of health and health inequities framework Refinement of operational definitions Some framework categories were easier to operationalize. “Agents” were consistently identifiable across materials because they mapped directly onto discrete individuals, organizations, or coalitions. Similarly, some “Structural Determinants” (“Ideas, Elections,” and aspects of the CTC) could be coded reliably, especially when interviewees were directly asked about them. However, several categories required definitional changes to enhance reliability. For example, we initially treated “Governance” and “Institutional Practices” separately in accordance with our original framework ( Karatekin et al . 2024 ), but then combined them because coders had difficulty differentiating between them. Interviewees’ descriptions often blurred lines between governance rules and everyday administrative and legislative practices. For example, the state constitution dictates the legislative session’s length (“Governance”), but how administration officials, legislators, and advocates use this to their advantage could be coded under “Institutional Practices.” One advocate noted, for instance, that “when you have a short legislative session, it's really hard for anybody but the insiders to have a perspective. So, having a longer session, one that's a bit more accessible, creates the opportunity for more voices to be heard.” The effects of the constitutional rule and the institutional practices are intertwined here. The coding process also revealed that certain types of “Power” were hard to separate in practice, necessitating clearer operational definitions and examples. For example, most “Power” codes fell under “Structural” and “Institutional Power” because formal roles, organizational hierarchies, institutionalized rules, and procedural authority dominate the policymaking process. However, coders found it hard to differentiate between the two and debated whether a particular action reflected the influence of a position itself (“Structural Power”) or a broader institutional context (“Institutional Power”). For example, “the two legislative leaders worked together with just a one-vote majority in the Senate to pass a long list of progressive goals” could be taken to reflect both “Structural” and “Institutional Power.” To address these challenges, we redefined “Structural/Institutional Power” to emphasize the influence of formal structures over individual behavior and added guidelines for overlapping instances. For example, references to the Democrats’ 2022–23 trifecta were always coded as “Structural/Institutional Power, Political Parties (as Agents),” and “Historical/Contextual Factors.” Similar ambiguities affected inter-coder reliability for the intersection of “Structural/Institutional” and “Discursive/Ideational Power.” “Discursive/Ideational Power” was hard to code reliably because its use depends on subtle language cues and narrative framing. The wording and framing of sentences, what one chooses to state and not to state or emphasize are all forms of “Discursive/Ideational Power.” However, this broad definition could lead to coding almost every public statement anyone in any position of “Power” made about the CTC as “Discursive/Ideational Power.” For example, when the governor gave press interviews about the CTC or proposed a budget that included the CTC, he was using both “Structural/Institutional” and “Discursive/Ideational Power.” In such cases, both kinds of “Power” were operating simultaneously. Thus, we clarified its definition with more examples and limited it to explicit references to language being used to shape discourse around the Minnesota CTC (e.g. debating whether it was a “tax cut,” or “government spending”; a reference to using the finding that the state CTC would reduce child poverty by 30% as “a selling point;” writing an op-ed). “Moral Power” created coding challenges due to its subjectivity. For example, statements about helping children or supporting families could be interpreted as moral, despite the lack of explicit moral language. “Moral” and “Discursive/Ideational Power” also overlapped, making it hard to determine when a statement reflected moral reasoning versus general framing. We adjusted the codebook and clarified that “Moral Power” should only be coded when the text explicitly included moral terms like “right or wrong,” which improved reliability. We added “Power of Lived Experience” to the types of “Power” to reflect the fact that some “Agents” were using their life experiences to support their arguments, an important contribution to the passing of the Minnesota CTC. This type of “Power” was not included in previous taxonomies, and other types of “Power” in the current taxonomy did not capture it. Although previously proposed dimensions of “Power” ( Harris et al . 2020 , Friel et al . 2021 , Popay et al . 2021 ) are important, they were hard to code in this study (e.g. spaces in which “Power” is exercised; visible versus invisible versus hidden “Power”). For example, “Moneyed Interests” undoubtedly played a role in bringing Democrats to power and in supporting core advocacy organizations, but they were not mentioned in the materials. With respect to invisible or hidden “Power,” it would be important to specify to whom it is invisible or hidden. For instance, the four organizations advocating for the Minnesota CTC were visible to Democratic leaders, but were barely mentioned by Republican interviewees or in the media. Thus, the process highlighted the complexity and necessity of including nuanced “Power” types in the framework. Frequent co-coding due to conceptual overlap between “Agents” and “Power” Certain “Agents” and “Power” types were consistently co-coded. Table 2 shows co-codes for the most frequently coded “Agents.” Table 2. Co-codes for agents and power for the most frequently coded agents. Discursive/ Ideational power Expert power Lived experience power Moral power Networking and lobbying power Personal attributes power Structural and institutional power Systemic power Agents Government Executive branch of the state government 11% 18% 4% 3% 20% 1% 74% 0% Federal government 20% 60% 0% 0% 0% 0% 20% 0% Legislative branch of the state government 10% 12% 6% 5% 23% 1% 77% 1% Other government 6% 11% 0% 0% 17% 0% 67% 0% Knowledge creators 13% 97% 3% 5% 15% 1% 29% 0% Media 64% 9% 9% 18% 36% 0% 36% 0% Moneyed interests 100% 0% 0% 0% 0% 0% 100% 0% Political parties 14% 7% 3% 2% 11% 1% 74% 1% The people Organized people 13% 22% 7% 1% 82% 0% 33% 1% Organized religion 15% 15% 13% 6% 80% 0% 28% 0% Unclear people 0% 7% 50% 7% 86% 0% 7% 0% Open in a new tab The numbers represent the total number of excerpts in which each type of “Power” was co-coded with each “Agent,” divided by the total number of excerpts referring to that “Agent.” For example, in the 291 excerpts in which the “Executive Branch of the State Government” was coded as the “Agent, Structural/Institutional Power” was also coded 74.2% of the time. Similar co-coding patterns emerged for two “Agents” (“Legislative Branch of the State Government” and “Political Parties”). Two other “Agents” (“Organized People” and “Organized Religion”) were more likely to be co-coded with “Networking/Lobbying Power.” Also, we changed the codebook to always co-code “Expert Power” with “Knowledge Creators” as “Agents,” as references to “Knowledge Creators” almost always reflected their “Expert Power” (e.g. when a news item reports a study on the poverty-alleviating effects of the CTC, the researchers have exercised power by influencing the media’s framing). These data indicate that “Agents” usually were described alongside the types of “Power” they exercised, so we combined them in the revised framework ( Fig. 1 ). Aim 2: extension of the agent- and power-centered social and structural determinants of health and health inequities framework Conjunction of factors Our second aim was to determine whether our framework needed to be extended. The most significant extension involved incorporating an overarching historical dimension (“temporal moment”) to illustrate the conjunction of events affecting the rest of the framework components, similar to Kingdon’s idea of “policy windows” ( Kingdon 1995 ). The basis for this extension was our observation of three factors emerging from the materials that catalyzed the law’s swift passage in two years but could not be accommodated within our original framework: the 2021 temporary expansion of the federal CTC, the historic state budget surplus of $17 billion, and the 2023–24 Democratic trifecta in Minnesota. These factors, which we labeled as “Historical/Contextual Factors,” were coded 247 times (131 times in 15 interviews, 88 in 141 news articles, and 28 in 12 legislative hearings and floor sessions). These data highlight the importance of key events that play a significant role in understanding how and which upstream factors impact public health. Historical roots It is also important to emphasize the historical dimension of each component, and how it arrived at the current moment. For example, the long-term work of the advocacy organizations in building power, their coalition-building efforts extending over at least a decade, their previous establishment of ties with the government and each other, and some “Agents’” transition from advocacy to government jobs all laid the foundation for the kind of successful advocacy these “Agents” engaged in to pass the Minnesota CTC. Thus, we added “Time” arrows to the framework to emphasize these historical roots. Bidirectional influences The WHO’s ( Solar and Irwin 2010 ) linear depiction of “Structural Determinants” influencing “Intermediary Determinants of Health and Health Inequities” de-emphasizes reverse influences, despite double-sided arrows. For instance, Minnesota’s accessible voting system and high voter turnout enabled the election of more representative “Agents,” impacting the laws and public health, which, in turn, likely influenced voter turnout. Similarly, “Governance and Institutional Practices” also affect how “Agents” exercise “Power.” For example, although all elected representatives enjoy a basic amount of “Power,” some have more depending on factors like committee assignments. Similarly, the Minnesota legislature’s practice of creating omnibus bills empowered the Tax Committee chairs to determine which legislation to include in them, enabling them to pass initiatives like the CTC. Thus, we reorganized the framework to better illustrate these bidirectional influences. Revised agent- and power-centered social and structural determinants of health and health inequities framework Figure 1 and Table 1 show revisions to the framework, including (i) merging “Agents” and “Power,” (ii) combining “Governance” and “Institutional Practices” (although we kept them separate in Fig. 1 ), (iii) combining “Structural” and “Institutional Power,” (iv) adding “Power of Lived Experience,” (v) incorporating ‘what power is used for’ in the “Power” analysis, (vi) shifting from two-dimensional to three-dimensional boxes to emphasize the components’ historical roots, (vii) introducing a Temporal Moment band around the entire framework to reflect the fact that the remaining components of the framework exist in a particular moment defined by a conjunction of historical and contextual factors, and (viii) adopting a less linear format with more prominent bidirectional arrows among components. Discussion We used our agent- and power-centered SSDHHI framework to conceptualize the passage of the Minnesota CTC, revealing its utility for real-world applications to analyze upstream determinants influencing health and health inequities. Aim 1: refinement of the components of the agent- and power-centered social and structural determinants of health and health inequities framework Agents and power Many SDH frameworks overlook the role of “Agents” and how they use “Power” to shape “Structural Determinants,” focusing instead on the outcomes of their actions (e.g. laws). Consequently, the “Agents” shaping “Structural Determinants” remain invisible, and recommended interventions do not focus on how “Power” can be used to support or counter them. In this study, we interviewed key players to identify “Agents” and uncover how they exercised “Power.” As shown in the column discrepancies in Supplementary Table S4 , they would not have been apparent had we relied solely on public materials, such as news articles or hearings. Results highlight the value of using diverse data sources to fully understand the influence of “Agents” and “Power” in creating structural change. Previous conceptualizations of “Power” were helpful but inadequate to conceptualize the “Power” dynamics in this case. These conceptualizations, based on expression, source, and levels of “Power” and spaces and arenas in which it operates ( National Collaborating Centre for Determinants of Health 2023 ), do not focus enough on operationalizing the terms or empirical testing. Thus, there is little reason to choose one over the other based on data. Moon’s typology ( Moon 2019 ) was the most useful for our case. Consequently, we are not advocating for a specific conceptualization of “Power”; different conceptualizations may be useful for different contexts and purposes. In addition, not every aspect of “Power” is relevant or practical to analyze in every case. However, based on our observations of this case, we noted four areas in which considerations of “Power” could be improved. 1. “Agents and Power.” Our original framework separated “Agents” and “Power” to emphasize both. However, they were challenging to separate during coding. In practice, when “Agents” use “Power,” it is often the “Power” they have access to, largely determined by their role or position. Thus, we combined these two components. Future researchers could identify “Agents” and delineate their “Power,” or focus on certain aspects of “Power” and examine which “Agents” are or are not using them. Additionally, some “Agents” might not use their “Power.” For example, the American Academy of Pediatrics could have advocated for the Minnesota CTC, but they did not. In this study, it would have been difficult to list all potential “Agents” and determine which ones refrained from using their “Power.” Thus, the “Agents” we identified were only those who were overt in their use of “Power.” In other cases, it may be more practicable to identify key potential “Agents” and examine which ones did not use their “Power” and why. Although “Agents” often use multiple forms of “Power” simultaneously, it can be productive to differentiate among them. For example, one could examine which types of “Agents” use which types of “Power” and why (e.g. the extent to which “Moral Power” is used by right-wing extremists or by marginalized groups), which potential types of “Power” are not being used adequately or are suppressed (e.g. to what extent are individuals using the “Power of Lived Experience” or shying away from it and in what contexts; what are effective ways to teach “Discursive/Ideational Power”?), or how use of “Power” by different “Agents” changes over time (e.g. does “Moral Power” get used more in times of uncertainty?). These analyses could guide not only research but also action. 2. “Types of Power.” Our taxonomy of “Power” was mostly adequate for this study. However, “Structural” and “Institutional Power” were hard to differentiate reliably, so we consolidated them. “Discursive/Ideational Power,” as defined by Moon (2019) , was too broad to be coded reliably, so we limited its definition to language being used explicitly by “Agents” to shape discourse. This narrower definition meant that results emphasized messaging and underestimated the use of “Discursive/Ideational Power.” For example, the “Media” undoubtedly shaped public opinion through “Discursive/Ideational Power,” but it was rarely coded as an “Agent” because it was not explicitly mentioned as relevant to the law’s passage. Thus, the operational definition and measurement of “Discursive/Ideational Power” need to be refined. We also had difficulty separating “Discursive/Ideational” from “Moral Power” and limited the definition of “Moral Power” to explicit references to morality, such as “right” or “just.” We added “Power of Lived Experience” to our list because it played a distinct role in this case and subsuming it under other forms of “Power,” like “Discursive/Ideational Power,” would diminish its unique importance. Lived experience often exerts influence through storytelling (“Discursive/Ideational Power”). However, while reading through our materials, it became clear that lived experience brought a unique power of its own that came with legitimacy, wisdom, and groundedness, based not just on what was said but who was speaking, and the value listeners placed on that experience. Testimony from individuals with lived experience likely carried weight not only because of the issue’s framing, but also because their experience brought credibility to decision-making. Although it often drew on multiple elements such as morality, experiential expertise, and narrative framing, coding it as a combination of these elements would have taken away from what it did as a distinct influence source. Additionally, co-coding those with lived experience as “Agents” and “Discursive/Ideational Power” seemed insufficient, as it would miss the mechanism by which people with lived experience exert influence and credibility. In future research, “Power of Lived Experience” can be used as an indication of the extent to which individuals with lived experience are being represented in different contexts (e.g. whether they are in the halls of “Power” or are listened to by those in “Power”), different forms of evidence valued in different contexts (e.g. science versus legislative hearings), and how these may change over time. “Power of Lived Experience” also highlights the necessity of participatory action research, the need to create empowering spaces, and take a bottom-up approach to understanding social policy, such that policies are not simply framed based on assumptions and observations from the top down. However, the “Power of Lived Experience” can cut both ways. It can be used for good because it represents first-hand experiences gained by individuals who have navigated specific challenges, and can allow them to inform, transform, and improve systems, policies, and support services. In other cases, it could be used to serve anti-science attitudes (e.g. putting lived experience over well-established scientific evidence) and as a means of delegitimizing science. In future conceptualizations, it could also be considered as a subcategory under “Discursive/Ideational Power.” Certain types of “Power,” such as “Economic/Financial Power” and “Systemic Power,” were rarely coded despite their pervasive influence because they were not mentioned in the materials. For instance, economic/financial resources certainly empowered key “Agents.” However, coding the financial underpinnings of advocacy organizations or the Democrats’ rise to power would have been challenging and hard to connect directly to the law’s passage. Similarly, “Systemic Power,” exemplified by the governor being a White male, was challenging to capture within standard coding methods. More research is necessary to better operationalize and measure these broader and more invisible types of power to ensure their impact is recognized. 3. “Dimensions of Power.” Various dimensions of “Power,” such as visibility ( Friel et al . 2021 ), were hard to code in this study, although we recognize their significance. More research is needed to clarify these dimensions. We make several suggestions for future considerations of “Power.” First, it is essential to distinguish between the exercise versus the extent of the impact of “Power.” For example, although Republicans in the Minnesota legislature voted against the omnibus bill containing the CTC, their “Power” had minimal impact, as they were in the minority. Additionally, considering the short versus long-term outcomes of “Power” (together with direct and indirect “Power”) in relation to “Structural Determinants” is crucial. For example, the Governor and Lieutenant Governor first met through the Wellstone Foundation, aimed at helping progressive individuals get elected. Thus, the Foundation had an indirect and long-term impact on the CTC’s passage by nurturing “Structural/Institutional Power,” despite not exercising direct “Power” in this case. This example also illustrates how the historical context and Temporal Moment (conjunctions of events and trends) are shaped by “Agents” and their use of “Power.” Another dimension is the extent to which potential “Power” is used and the persistence of the “Agents” in using it. For example, Governor Walz could have mentioned the CTC in passing; however, he prioritized it in speech after speech. A coalition supporting raising the minimum wage that united in Minnesota in 2013–14 also persisted in their advocacy and built “Power” in the state legislature and administration, which facilitated the CTC’s passage in 2023. One could also consider the skill with which “Power” is used, which is different from its outcomes, and how to build these skills. For example, the state Democratic leadership worked together skillfully to take full advantage of the “Structural/Institutional Power” that came with a trifecta to pass the CTC, and advocates used their “Networking Power” skillfully to craft a letter of support to draw in 41 other organizations. The advocates also used their “Discursive/Ideational Power” adeptly to present different framings of the CTC to Democrats versus Republicans. The extent to which intended targets of “Power” are open to being influenced is another possible dimension. In this case, scientists had “Expert Power” because the state administration was open to considering scientific evidence in policy-making. Similarly, the advocates had “Lobbying Power” because the legislators and state administration were open to working with them. Although irrelevant in this case, “Power” dimensions can also include the extent to which it is abused versus used within legal limits. 4. “Why use Power”? Finally, the most important aspect of “Power” is what it is used for, as well as the interacting motivations of “Agents.” As President Johnson said when informed that fighting for civil rights would jeopardize his chances in the 1964 election, “well, what the hell is the presidency for?” ( Caro 2012 ). Previous conceptualizations of “Power” do not mention this aspect, and we did not code it. However, differences in various “Agents’” motivations and how they negotiated them were noteworthy. For example, Democrats and the core advocacy group exercised their “Power” to use the CTC to reduce child poverty. The Catholic Conference also used its “Power” to enable mothers to stay at home if they chose to. Republicans were motivated more by a desire to help parents pay for child care so they could work. Interestingly, these different, and somewhat conflicting, motivations converged in this case to pass the law. Structural determinants We could identify and operationalize most of the “Structural Determinants” in our framework, bringing greater clarity to the term. However, it was difficult to reliably separate “Governance” from “Institutional Practices,” so we combined them in this study. It might be possible to reliably differentiate between them in other scenarios. In future studies, another solution might be to define “Governance” in very broad terms (e.g. unicameral versus bicameral government, three separate but equal branches of government, presence versus absence of term limits, democracy versus authoritarianism) and define “Institutional Practices” in terms of how work is accomplished within these broad parameters. Aim 2: extension of the agent- and “Power”-centered social and structural determinants of health and health inequities framework Our framework, like the WHO framework it is based on, lacked a temporal dimension, limiting its ability to capture the historical context surrounding the Minnesota CTC’s passage. Each element of the framework has its own historical trajectory. For example, one can examine historical changes in the use of different types of “Power” by different “Agents”; “Stratifiers” (e.g. trends in population demographics or in resource allocation according to demographic characteristics); “Structural Determinants” (e.g. changes in the “Election System” and implications for who holds “Power”); or “Intermediary Determinants” (e.g. changes in housing conditions). To depict this point, we enhanced the framework by making the boxes three-dimensional and adding a time component. These “time” arrows emphasize that each component is historically rooted and dynamic. It is crucial not to overlook the interactions and feedback loops among these trajectories. Additionally, distinguishing between discrete events with long-term impacts (e.g. a pandemic) versus long-term trends (e.g. rising income inequality) could provide deeper insight into their mutual influences. Moreover, considering the bidirectional influences among “Agents,” “Power,” “Structural Determinants,” and more downstream determinants, we added bidirectional arrows among components to depict the framework in a less linear manner. In addition, discrete events, their conjunctions, and broader historical trends can influence SSDHHI, creating periods of crisis and opportunity not captured by individual trajectories. The time scale of these conjunctions could vary. An example of short-term conjunction of events is that the Minnesota CTC would likely not have passed without the combination of the COVID-19 pandemic, the subsequent 2021 expansion of the federal CTC, the resulting unusually large state budget surplus, and the Democratic trifecta in Minnesota. A longer-term analysis of the state CTC’s passage might consider, e.g. the conjunction of the trajectory of neoliberalist thought that led to using the tax system to provide financial assistance to children and requiring their parents to work ( McCabe and Popp Berman 2016 ), increasing dominance of extremely wealthy individuals in US government, the resulting growth in income inequality ( Wallace et al . 2022 ), the urgent needs of those living and working in poverty laid bare during the early years of the COVID-19 pandemic, and the story of the organizing that led to the Democratic trifecta in Minnesota in 2022. Thus, our framework can be used both to examine a moment in time (as in this study) as well as the historical roots of the current moment and how a conjunction of events enabled it. This also brings up the issue of the weights that should be given to different factors leading to an outcome. For example, one could distinguish between historically proximal versus distal factors, or factors with different levels of centrality or the strength of the effect they produced. Generalizability of the framework Although any case study is inevitably bound by its context, the fundamental components (“Agents,” “Power,” “Structural and Intermediary Determinants,” and “Stratifiers”) and dynamics in our revised framework are generalizable to analyzing causes of health and health inequities in most contexts, from countries with different socioeconomic and political structures to more local levels (e.g. city government or a health care system), specific institutions (e.g. a university or a corporation), and different historical eras. One can decide how deep to dig to search for root causes (e.g. the framework can be used to understand how student health is influenced by upstream factors within a university or by global corporations) and how far back to go in time. There are “Agents” in all these contexts, and they all use some kind of “Power,” although the ways in which they operate and exercise “Power” and their relative importance vary. All these contexts have some kind of “Governance and Institutional Practices, Laws and Policies,” a system for bringing individuals or parties to positions of “Power, Stratifiers” by which resources are allocated, and “Intermediary Determinants.” They all exist within “Broader Geopolitical, Sociopolitical, and Economic Systems and underlying Ideas.” Everything happens within temporal moments, and one can analyze the historical roots of all these components. The framework is also neutral as to whether the policies are good for public health or detrimental to it, and whether policy attempts have failed or succeeded. Recommendations for future research This study is the first time a case study was used to systematically test and refine our agent- and power-centered SSDHHI framework. We recommend using it to analyze other cases and to compare cases, both to understand the cases better and to further improve the framework. Ideas are arguably the most important “Structural Determinants,” but are ignored in some public health frameworks, perhaps because they are difficult to measure. In this study, we provided a method for uncovering these “Ideas” by using thematic analysis. This method enabled us to go beyond equating “Ideas” with overt messages to get at underlying worldviews (see Supplementary Table S1 ). “Ideas” and “Discursive/Ideational Power” are related: Existing “Ideas” in society could be wielded to exercise “Discursive/Ideational Power,” and “Discursive/Ideational Power,” in turn, could be used to shape “Ideas.” We suggest more research on “Ideas” underlying SSDHHI and how they interact with different aspects of “Power.” For example, future research could examine how “Ideas” intersect with “Discursive/Ideational Power” or “Moral Power” by investigating dominant or subversive “Ideas” in an area and analyzing how language is used by different “Agents” to push specific “Ideas” forward or push back against them. The extension of our framework to incorporate historical roots and intersections of events could be combined with conjunctural analysis in future studies. Both approaches are concerned with the combination of societal and historical factors that affect the current moment and how “Power” can be used to leverage these factors to improve societal wellbeing ( Gilbert et al . 2013 , Peck 2024 ). Using different frameworks to analyze the same outcome can also reveal their strengths and weaknesses in leading to a deeper understanding of cases and to meaningful action. These comparative analyses would also bring up questions of how to evaluate descriptive frameworks. Qualitative research with diverse data sources was essential to unearthing upstream determinants in the case of the passage of the Minnesota CTC. As shown in Supplementary Table S4 , there were some large discrepancies in frequency of references to various framework components across interviews, news, items, and hearings. In particular, it would not have been possible to obtain a comprehensive view of this law’s passage without the information provided during interviews with diverse types of “Agents” (state administration, legislators, and advocates). Finally, we hope that this agent- and power-centered SSDHHI framework does not become depoliticized and misinterpreted, as the WHO’s SDH framework has been ( Karatekin et al . 2024 ). Our goal is to highlight upstream determinants of health and health inequities, rather than focusing solely on downstream interventions. Although research on the outcomes of laws and policies is crucial, we encourage greater consideration of other upstream factors that influence these laws and policies in research designs and when contextualizing study findings. How can the agent- and power-centered social and structural determinants of health and health inequities framework be used to guide action? A comprehensive understanding of the “Determinants” affecting health and health inequities, including the key “Agents” in a given case and how they use their “Power,” can identify intervention targets and strategies for obtaining and using “Power” to drive policy change and improve public health. “Power” dynamics It is important to analyze for any given case how key “Agents” obtain, build, maintain, and use different types of “Power”; how “Power” is allocated across “Agents”; how well “Agents” combine different types of “Power” and work with other “Agents” to increase their “Power”; how they challenge each other; and how these “Power” dynamics can be leveraged to improve public health. In the current case, e.g. one advocacy group (Minnesota Budget Project) obtained some of their “Power” through building well-respected expertise in budget analysis and through consistent advocacy in the state legislature. Furthermore, the coalition of the advocacy groups in this case had more “Power” than if they acted alone. Democratic leaders in the administration and legislature worked together effectively, thereby increasing their “Power.” The Lieutenant Governor was given “Power” over progressive policies in the administration, and she was able to combine her “Structural/Institutional Power” with the “Power of Lived Experience” to make a stronger case. The Catholic Conference combined their “Lobbying Power” with “Moral Power” to appeal to Republicans. Conjunctions of events and historical trends How can these conjunctions be used as opportunities for action to improve public health? The Minnesota Democrats, e.g. took advantage of the combination of the historically large budget surplus and their brief trifecta to pass a broad array of laws, including the CTC. Structural determinants How do specific “Structural Determinants” facilitate or hinder “Agents” and their “Power,” and how can they be modified to improve public health? How do these “Structural Determinants” differentially affect “Agents”? For example, the Minnesota state constitution gives the governor much “Power” over the budgeting process, which Governor Walz used effectively to pass the CTC. Minnesota’s “Election System” enabled a representative group of individuals to be elected, giving them “Structural/Institutional Power.” Conclusion Frameworks are tools for thinking about phenomena. How we conceptualize the systems we live in can impact our experience of those systems, our awareness of the types of “Power” we can exercise, and our actions. Public health frameworks can guide attention, research, and action toward certain factors and away from others and thereby shape public health and health inequities. The WHO’s SDH framework ( Solar and Irwin 2010 ) guided attention toward upstream determinants but not those who influence those determinants. It also failed to operationalize ‘culture and societal values.’ As a result, these vaguely defined upstream determinants seem to exist in a vacuum, divorced from the politics and “Power” dynamics that produce them and the narrative frames in which they are embedded. Heller and colleagues (2024) guided attention toward considerations of “Power” and provided better definitions of “Structural Determinants.” However, their conceptualization did not emphasize the “Agents” who wield “Power.” The current framework builds on and extends these previous frameworks by explicitly including “Agents,” who wield “Power” over “Structural Determinants,” which then influence “Intermediary Determinants,” which ultimately impact health and health inequities. Analyzing the passage of the Minnesota CTC within this agent- and power-centered SSDHHI framework revealed strengths and weaknesses of the framework, leading us to recommend refining several components and extending it by adding a temporal dimension. We hope further research can advance this work to achieve a more complete understanding of the factors that determine health and health inequities and what can be done to improve them. Supplementary Material daag072_Supplementary_Data daag072_supplementary_data.zip (6.3MB, zip) Acknowledgments We are grateful to Bria Gresham and Rachel Kritzik for their help with the initial stages of thinking about the study and with reviewing and editing the manuscript; to Rachel Kritzik for her suggestion regarding the simplification of the figure; the two pilot interviewees; Dr Benjamin Toff at the University of Minnesota for providing us with the list of local news sources; Molly Niehls at the library of the state legislature for providing links to the hearings and the “Daily Session” articles; and Tim Whisler, Ashley Aker, Anna Voronkova, Annika Mellum, and Ashley Aker for their help with coding. This study would not have been possible without the generosity of the interviewees in giving us their time and telling their story of the passage of the law and the help of their assistants. No artificial intelligence was used in the writing of this manuscript. Contributor Information Canan Karatekin, Institute of Child Development, University of Minnesota, 51 E. River Road, Minneapolis, MN 55455, United States. Shruti Chakraborty, Department of Applied Psychology, University of Delhi, Benito Juarez Marg, South Campus, South Moti Bagh, New Delhi 110021, India. Maya Fteiha, Institute of Child Development, University of Minnesota, 51 E. River Road, Minneapolis, MN 55455, United States. Frederique Corcoran, Institute of Child Development, University of Minnesota, 51 E. River Road, Minneapolis, MN 55455, United States. Unnati Khanna, Department of Psychology, School of Psychological Sciences, Christ (Deemed to be University) Delhi NCR, Nandgram Rd, Marium Nagar, Sewa Nagar, Ghaziabad, Uttar Pradesh 201003, India. Susan Marshall Mason, Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, 1300 S. 2nd St., Room 300 West Bank Office Building, Minneapolis, MN 55454, United States. Andrew J Barnes, Department of Pediatrics, Medical School, University of Minnesota, 2025 E. River Parkway, Minneapolis, MN 55455, United States. Author contributions Canan Karatekin (Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Supervision, Writing—original draft, Writing—review & editing), Shruti Chakraborty (Formal analysis, Investigation, Methodology, Visualization, Writing—original draft, Writing—review & editing), Maya Fteiha (Formal analysis, Visualization, Writing—original draft, Writing—review & editing), Frederique Corcoran (Conceptualization, Formal analysis, Investigation, Methodology, Writing—original draft, Writing—review & editing), Unnati Khanna (Conceptualization, Investigation, Methodology, Visualization, Writing—review & editing), Susan Marshall Mason (Conceptualization, Writing—review & editing), and Andrew J. Barnes (Conceptualization, Writing—review & editing) Supplementary material Supplementary material is available at Health Promotion International online. Conflicts of interest The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding None declared. Data availability Data on the coding of the news items and hearings and aggregate data on all the materials can be made available to interested individuals. However, we will not make interview transcripts available to preserve the anonymity of the interviewees. Ethical approval The University of Minnesota Institutional Review Board determined the study to be “Not Human Research” (STUDY00023704). References Braun  V, Clarke  V. Using thematic analysis in psychology. Qual Res Psychol  2006;3:77–101. 10.1191/1478088706qp063oa [ DOI ] [ Google Scholar ] Braun  V, Clarke  V. Thematic analysis. 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Res Soc Stratif Mobil  2022;78:100677. 10.1016/j.rssm.2022.100677 [ DOI ] [ Google Scholar ] Associated Data This section collects any data citations, data availability statements, or supplementary materials included in this article. Supplementary Materials daag072_Supplementary_Data daag072_supplementary_data.zip (6.3MB, zip) Data Availability Statement Data on the coding of the news items and hearings and aggregate data on all the materials can be made available to interested individuals. However, we will not make interview transcripts available to preserve the anonymity of the interviewees. 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