Recent public health scholarship finds that health outcomes are explained by the social and individual determinants of health rather than the individual-level determinants alone. The individualistic perspective has dominated the 20th century institutionalization of public health in the United States where the public health system has tended to focus largely, if not exclusively, on individual factors. This persistent orientation lies in contrast to another set of perspectives that have also persisted, focused on social causes, which are currently dominant in contemporary public health academic literature and in major, international health organizations. Whether the orientation within the United States is due to a prevailing paradigm among public health officials or is the result of new ideas about health causation being dampened under organizational weight is unknown. Despite public health being central to decreasing morbidity and mortality in the 20th century, significant gaps remain in researchers' understanding of what influences practice in the American public health system.

My dissertation research investigates the broad outlines of the determinants of health as understood by state public health administrators. I study how the understanding of the determinants of health affects the practice of public health through analyzing how the ideas of state public health administrators interact with the organizational dynamics of the public health organizations they lead. This mixed-methods dissertation uses survey research and in-depth interviews and quantitative and qualitative analysis.

I find that state public health officials' professionalization, length of tenure, level of education, and gender affect the perspective of health causation to which they adhere. I also find that the state public health officials with a social health frame more commonly report they are situated in organizations that are learning environments. Both organizational and ideational factors influence public health practice. The interview data expand this finding to paint a complex picture of organizational and ideational factors influencing one another as well as resulting practices. This research reveals that state public health officials often have strong health frames that are only able to shape the edges of their practice due to the political and organizational dynamics interacting with state public health departments.