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What do we mean by ‘structure’ when we talk about structural influences on the social determinants of health inequalities?

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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.

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References

  • Abel, T. and Frohlich, K. L. (2012) Capitals and capabilities: Linking structure and agency to reduce health inequalities. Social Science and Medicine, 74(2), 236–244.

    Article  Google Scholar 

  • Atkinson, A. B. and Leigh, A. (2007) The distribution of top incomes in Australia. The Economic Record, 83, 247–261.

    Article  Google Scholar 

  • Australian Institute of Health and Welfare. (2014) National Drug Strategy Household Survey Detailed Report 2013. Canberra: AIHW.

    Google Scholar 

  • Beck, U. (1992) Risk Society: Towards a New Modernity. London: Sage.

    Google Scholar 

  • Begg, S. J., Vos, T., Barker, B., Stanley, L. and Lopez, A. D. (2008) Burden of disease and injury in Australia in the new millennium: Measuring health loss from diseases, injuries and risk factors. MJA, 188(1), 36–40.

    Google Scholar 

  • Bourdieu, P. (1962) The Algerians. Boston: Beacon Press.

    Google Scholar 

  • Bourdieu, P. (1972) Outline of a Theory of Practice. Cambridge: Cambridge University Press.

    Google Scholar 

  • Bourdieu, P. (1984) Distinction: A Social Critique of the Judgement of Taste. London: Routledge.

    Google Scholar 

  • Bourdieu, P. (1986) The forms of capital. In: J. Richardson (ed.) The Handbook of Theory: Research for the Sociology of Education. New York: Greenwood Press, pp. 241–258.

    Google Scholar 

  • Bourdieu, P. (1987) What makes a social class? On the theoretical and practical existence of groups. Berkeley Journal of Sociology, 32, 1–17.

    Google Scholar 

  • Bourdieu, P. and Wacquant, L. (1992) Invitation to Reflexive Sociology. Chicago: Chicago University Press.

    Google Scholar 

  • Braveman, P., Cubbin, C., Egerter, S., Williams, D. R. and Pamuk, E. R. (2010) Socioeconomic disparities in health in the United States: What the patterns tell us. American Journal of Public Health, 100(Suppl 1), S186–S196.

    Article  Google Scholar 

  • Brennan, P., Crispo, A., Zaridze, D., Szeszenia-Dabrowska, N., Rudnai, P., Lissowska, J. et al (2006) High cumulative risk of lung cancer death among smokers and nonsmokers in Central and Eastern Europe. American Journal of Epidemiology, 164(12), 1233–1241.

    Article  Google Scholar 

  • Burchell, G. (1993) Liberal government and techniques of the self. Economy and Society, 22(3), 267–282.

    Article  Google Scholar 

  • Cingano, F. (2014) Trends in income inequality and its impact on economic growth. OECD Social, Employment and Migration Working Papers 163.

  • Commission on Social Determinants of Health. (2008) Closing the Gap in a Generation. Geneva: World Health Organization.

    Google Scholar 

  • Dean, M. (2010) Governmentality: Power and Rule in Modern Society. 2nd ed. London: Sage Publications.

    Google Scholar 

  • Dennis, S. (2007) Four milligrams of phenomenology: An anthrophenomenological analysis of smoking cigarettes. Popular Culture Review Journal, 17(1), 41–57.

    Google Scholar 

  • Dennis, S. (2011) Smoking causes creative responses: on state antismoking policy and resilient habits. Critical Public Health, 21(1), 25–35.

    Article  Google Scholar 

  • Doll, R. and Hill, A. B. (1954) The mortality of doctors in relation to their smoking habits. BMJ, 1(4877), 1451–1455.

    Article  Google Scholar 

  • Federico, B., Mackenbach, J. P., Eikemo, T. A., Sebastiani, G., Marinacci, C., Costa, G. et al (2013) Educational inequalities in mortality in northern, mid and southern Italy and the contribution of smoking. Journal of Epidemiology and Community Health, 67(7), 603–609.

    Article  Google Scholar 

  • Foucault, M. (1979) The History of Sexuality: Volume 1. An Introduction. London: Allen Lane.

    Google Scholar 

  • Foucault, M. (2000) Governmentality. In: J. D. Faubion (ed.) Foucault: Power. New York: New Press, pp. 201–222.

    Google Scholar 

  • Frohlich, K. L., Corin, E. and Potvin, L. (2001) A theoretical proposal for the relationship between context and disease. Sociology of Health & Illness, 23(6), 776–797.

    Article  Google Scholar 

  • Galobardes, B., Shaw, M., Lawlor, D. A., Lynch, J. W. and Davey Smith, G. (2006) Indicators of socioeconomic position (part 1). Journal of Epidemiology and Community Health, 60(1), 7–12.

    Article  Google Scholar 

  • Gilbert, E. (2005) Contextualising the medical risks of cigarette smoking: Australian young women’s perceptions of anti-smoking campaigns. Health, Risk & Society, 7(3), 227–245.

    Article  Google Scholar 

  • Global Burden of Disease Study 2013 Collaborators. (2015) Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: A systematic analysis for the Global Burden of Disease Study 2013. The Lancet, 386(9995), 743–800.

    Article  Google Scholar 

  • Katainen, A. (2006) Challenging the imperative of health? Smoking and justifications of risk-taking. Critical Public Health, 16(4), 295–305.

    Article  Google Scholar 

  • Katainen, A. (2010) Social class differences in the accounts of smoking—Striving for distinction? Sociology of Health & Illness, 32(7), 1087–1101.

    Article  Google Scholar 

  • Link, B.G. and Phelan, J. (1995) Social conditions as fundamental causes of disease. Journal of Health and Social Behavior Extra Issue: 80–94.

  • Lupton, D. (1995) The Imperative of Health: Public Health and the Regulated Body. London: SAGE Publications.

    Google Scholar 

  • Lupton, D. (2013) Risk. 2nd ed. London: Routledge.

    Google Scholar 

  • Mackenbach, J. P., Stirbu, I., Roskam, A.-J. R., Schaap, M. M., Menvielle, G., Leinsalu, M. et al (2008) Socioeconomic inequalities in health in 22 European countries. New England Journal of Medicine, 358(23), 2468–2481.

    Article  Google Scholar 

  • Macleod, J. and Davey Smith, G. (2003) Author’s reply to A. Singh-Manoux ‘Psychosocial factors and public health’. Journal of Epidemiology & Community Health 57(8): 554–556.

  • Marmot Review. (2010) Fair society, healthy lives: Strategic review of health inequalities in England post-2010. Department of Health, London.

  • Martikainen, P., Ho, J. Y., Preston, S. and Elo, I. T. (2013) The changing contribution of smoking to educational differences in life expectancy: Indirect estimates for Finnish men and women from 1971 to 2010. Journal of Epidemiology and Community Health, 67(3), 219–224.

    Article  Google Scholar 

  • Michell, L. and Amos, A. (1997) Girls, pecking order and smoking. Social Science and Medicine, 44(12), 1861–1869.

    Article  Google Scholar 

  • Mikkonen, J. and Raphael, D. (2010) Social determinants of health: The Canadian facts. Toronto: York University School of Health Policy and Management.

    Google Scholar 

  • Muntaner, C., Ng, E., Chung, H. and Prins, S. J. (2015) Two decades of Neo-Marxist class analysis and health inequalities: A critical reconstruction. Social Theory & Health, 13(3–4), 267–287.

    Article  Google Scholar 

  • Ng, E. and Muntaner, C. (2014) A critical approach to macrosocial determinants of population health: Engaging scientific realism and incorporating social conflict. Current Epidemiology Reports, 1(1), 27–37.

    Article  Google Scholar 

  • Oakes, J. M. and Kaufman, J. S. (eds.) (2006) Methods in Social Epidemiology. San Francisco: Jossey-Bass.

    Google Scholar 

  • Pampel, F. C. (2006) Socioeconomic distinction, cultural tastes, and cigarette smoking. Social Science Quarterly, 87(1), 19–35.

    Article  Google Scholar 

  • Peto, R., Darby, S., Deo, H., Silcocks, P., Whitley, E. and Doll, R. (2000) Smoking, smoking cessation, and lung cancer in the UK since 1950: Combination of national statistics with two case-control studies. BMJ, 321(7257), 323–329.

    Article  Google Scholar 

  • Phelan, J. C., Link, B. G. and Tehranifar, P. (2010) Social conditions as fundamental causes of health inequalities: Theory, evidence, and policy implications. Journal of Health and Social Behavior, 51(Suppl 1), S28–S40.

    Article  Google Scholar 

  • Piketty, T. (2003) Income inequality in France, 1901–1998. Journal of Political Economy, 111(5), 1004–1042.

    Article  Google Scholar 

  • Piketty, T. and Saez, E. (2003) Income inequality in the United States, 1913–1998. Quarterly Journal of Economics, 68(1), 1–39.

    Article  Google Scholar 

  • Pini, B., McDonald, P. and Mayes, R. (2012) Class contestations and Australia’s resource boom: The emergence of the ‘cashed-up bogan’. Sociology, 46(1), 142–158.

    Article  Google Scholar 

  • Pini, B. and Previte, J. (2013) Bourdieu, the boom and cashed-up bogans. Journal of Sociology, 49(2–3), 256–271.

    Article  Google Scholar 

  • Poland, B., Frohlich, K., Haines, R., Mykhalovskiy, E., Rock, M. and Sparks, R. (2006) The social context of smoking: The next frontier in tobacco control? Tobacco Control, 15(1), 59–63.

    Article  Google Scholar 

  • Rahkonen, O., Laaksonen, M. and Karvonen, S. (2005) The contribution of lone parenthood and economic difficulties to smoking. Social Science and Medicine, 61(1), 211–216.

    Article  Google Scholar 

  • Rose, G. (1985) Sick individuals and sick populations. International Journal of Epidemiology, 14(1), 32–38.

    Article  Google Scholar 

  • Scambler, G. (2013) Resistance in unjust times: Archer, structured agency and the sociology of health inequalities. Sociology, 47(1), 142–156.

    Article  Google Scholar 

  • Schaap, M. M. and Kunst, A. E. (2009) Monitoring of socio-economic inequalities in smoking: Learning from the experiences of recent scientific studies. Public Health, 123(2), 103–109.

    Article  Google Scholar 

  • Schaefer, D. R., Haas, S. A. and Bishop, N. J. (2012) A dynamic model of US adolescents’ smoking and friendship networks. American Journal of Public Health, 102(6), e12–e18.

    Article  Google Scholar 

  • Sewell, W. H., Jr. (1992) A theory of structure: Duality, agency, and transformation. American Journal of Sociology, 98(1), 1–29.

    Article  Google Scholar 

  • Solar, O. and Irwin, A. (2007) A conceptual framework for action on the social determinants of health: Discussion paper for the Commission on Social Determinants of Health. Geneva: World Health Organization.

  • United Nations. (2015) The Global Goals. www.globalgoals.org. Accessed 30 September 2016.

  • Wakefield, M. A., Durkin, S., Spittal, M. J., Siahpush, M., Scollo, M., Simpson, J. A. et al (2008) Impact of tobacco control policies and mass media campaigns on monthly adult smoking prevalence. American Journal of Public Health, 98(8), 1443–1450.

    Article  Google Scholar 

  • Woodward, S. (1984) Trends in cigarette consumption in Australia. Australian and New Zealand Journal of Medicine, 14(4), 405–407.

    Article  Google Scholar 

  • Wright Mills, C. (1959) The Sociological Imagination. New York: Oxford University Press.

    Google Scholar 

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Authors and Affiliations

  1. Michael Kirby Centre for Public Health and Human Rights, Monash University, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, 3004, Australia

    Bradley R. Crammond

  2. Centre for Public Service Research, Business School, UNSW Canberra, Canberra, Australia

    Gemma Carey

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  1. Bradley R. Crammond
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  2. Gemma Carey
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Correspondence to Bradley R. Crammond.

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Crammond, B.R., Carey, G. What do we mean by ‘structure’ when we talk about structural influences on the social determinants of health inequalities?. Soc Theory Health 15, 84–98 (2017). https://doi.org/10.1057/s41285-016-0020-3

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