What do we mean by structure when we talk about structural influences on the social determinants of health and health outcomes?

Abstract

Understanding and modifying the influence of structural factors on health is one of the core aims of contemporary public health. The currently dominant account in public health treats structure as being synonymous with indicators of social status such as income, education or occupation level. The unequal distribution of these indicators is further treated as the 'fundamental cause' of health inequalities. In this paper we build an account of structure which is grounded in social theory and responsive to the empirical evidence on health inequalities. We start with Bourdieu's model of habitus which positions social structures more proximally to the individual and redraws the hierarchy of up-, mid- and downstream influences. Bourdieu's theory does not adequately account for the role of public health interventions in changing attitudes and behaviours and it is particularly ill-suited to explaining the considerable reductions in smoking prevalence seen in industrialised countries. For these reasons we supplement habitus with Foucault's notion of governmentality. Structural influences on health behaviour are understood to combine equally with the myriad individual concerns of daily life. Describing some structures as being 'fundamental causes' owing to their distant position from the individual leads to misunderstanding the crucially important roles of all levels of structure.