There are two contrasting theoretical traditions through which a notion of health capital for understanding the individual construction of health could be conceptualized: human capital theory in the tradition of the Chicago school of economics and Bourdieu’s work on the forms of capital.
Human capital theoretic perspective
Through a human capital theoretic perspective, such a conceptualization of health capital could be viewed as a capital stock of dual nature, one that could be an input as well as an outcome of production processes. When health capital is viewed as an input, any investment of individuals into their health capital would be made with the goal of using it as an asset in obtaining material returns through the production of healthy time (Grossman 1972). Grossman would refer to health capital in this sense as an investment commodity. While health capital clearly could be an asset in the production of market goods and other commodities, the construction of individual health could also be viewed as an end in itself. In this sense, it could be viewed as the outcome of the production processes of the consumption commodity health capital driven by the “fundamental demand for ‘good health’” (Grossman 1972, p. 248). The duality of health capital would rest on the conversion of different forms of human and economic capital within standard market forces, i.e., through the exchange of money, market goods, and commodities.
Human capital theory also has a long tradition of considering specific forms of human capital: from general-purpose and industry-specific to firm-, occupation-, and task-specific human capital (Gibbons and Waldman 2004). Task-specific human capital takes up Smith’s (1776) view on task-specific specialization as a driver of productivity and is based on the idea that “much of the human capital accumulated on the job is due to task-specific learning by doing” (Gibbons and Waldman 2004, p. 203). Health capital as a conceptual framework for understanding the construction of individual health could be viewed as task-specific at different scales: from tasks such as the patient-specific day-to-day management of chronic illnesses like diabetes (Scambler et al. 2014) to more general tasks such as the prevention of lifestyle diseases through individual exercise and dieting advocated by health promotion campaigns (Ayo 2012).
Human capital theory often draws upon a homogeneity assumption as, e.g., formulated by Stigler and Becker (1977, p. 76): “rules and tastes are stable over time and similar among people.” Nevertheless, in regard to health, there is an acknowledgement that, on the input side, the effectivity of the process of producing good health depends on “certain environmental variables” such as “the level of education of the producer” (Grossman 1972, p. 225). Likewise, on the output side, the investment in health is associated with side effects, often referred to as positive externalities in the literature on human capital theory (Ciccone and Peri 2006). These environmental variables, positive externalities, and other external factors are inherently outside the scope of human capital theory (Tan 2014), a priori limiting the potential value of a conceptualization of health capital through human capital theory.
A conceptualization of health capital from a Bourdieusian perspective would have the potential to capture such factors through the concept of social fields, which embed the rules, the agents, and relations of a particular domain of activity (Bourdieu 1984). The agents strive for social distinction within the field, accumulating symbolic capital in the form of recognition and status. This symbolic capital complements the economic, social, and cultural capital that shapes their class belongingness. Class and status, in turn, structure the agents’ capacities and dispositions. Bourdieu (1986) views capital as accumulated labor that has the capacity to affect the social positions of agents in a field.
Bourdieu and Wacquant (1992) introduce the notion of “field-dependency” of capital to signify how capital determines the social positions of the agents within a given field depends on the specific rules and relations of that field. This could open up for understanding health capital as field-dependent capital, determining the social positions of the agents within the social field of health. Here, the social field of health includes not only institutionalized health encounters in the form of interactions between patients and health professionals but also individuals’ everyday health practices outside of institutionalized contexts. Health capital could then be viewed as a unique form of capital different from but drawing upon the synergy of economic, social, cultural, and symbolic capital contextualized to the social field of health.
Economic capital plays a significant role in constructing individual health and shaping everyday health practices. Besides the purchase of medical services or products when one faces a medical condition, economic resources affect whether and how one implements a healthy lifestyle, e.g., through the consumption of (super)foods perceived to offer health benefits (Kamiński et al. 2020) or through personal trainers and self-tracking (Pantzar and Ruckenstein 2015). Unsurprisingly, statistics indicate a significant positive correlation between economic capital and life expectancy (Chetty et al. 2016).
Social capital contributes likewise to the construction of individual health. Family members and close personal acquaintances have always played a significant role in everyday health practices. Individual health has been found to depend on both the health and the health attitudes of family members (Jacobson 2000). Social capital in the form of strong social relations is correlated with good health (Turner 2003), in general, and longer life expectancy (Kennelly et al. 2003), in particular. Another important source of health-related social capital is patient associations, where sufferers unite in order to support each other (Carlsson et al. 2006), and online health communities, which offer connectivity and social support independent of geographical and class belongingness (Kingod et al. 2017).
Cultural capital plays a significant role in understanding how culture shapes health inequality (Dubbin et al. 2013; Shim 2010) and health-related help-seeking practices (Doblytė 2019). Cultural embeddedness, whether innate or acquired through media exposure, may open up access to alternative medical services or products (Thompson and Troester 2002). Prieur and Savage (2011) argue that cultural capital is to some degree dependent on the cultural context, with a bias toward a global orientation. Schneider-Kamp and Askegaard (2019) show how more general and globalized competences and attitudes play at least as important a role in the construction of individual health as more locally contextualized cultural aspects.
A general attitude of self-efficacy (Bandura 1977) combined with health information-seeking behaviors (Weaver et al. 2010) is providing a natural ground for the proliferation of “health literacy” or “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (Ratzan and Parker 2000, p. 147). This form of cultural capital becomes embodied over time and encourages an “ethic of self-conduct,” where individuals are viewed as “competent” if they are successfully “acquiring the skills and making the choices to actualize” themselves (Rose 1999). In the context of mental health services, initiatives built on the idea of expertise by experience actively encourage the accumulation of such cultural capital (Toikko 2016).
While Shim’s (2010) cultural health capital focuses on the role of culture in health encounters, Doblytė (2019, p. 287) argues that both cultural health capital and social capital that “can be converted into cultural health capital” are crucial in the study of mental health services. A conceptualization of health capital that integrates forms of capital other than cultural capital would allow for reflecting upon how, for example, social capital in the form of social embeddedness influences the construction of individual health without having to consider its conversion into cultural capital.
The relevance of taking multiple forms of capital into account when studying health is already described by Abel (2008, p. 1), who finds that “class related cultural resources interact with economic and social capital in the social structuring of people's health chances and choices.” A Bourdieusian perspective, thus, could offer a holistic view on the synergy of the forms of capital and allow for capturing the social and cultural embeddedness of contemporary health practices and health discourse. It could provide not only an opportunity for a deep investigation of the how but also the potential to explain the why in the construction of individual health by considering the symbolic aspects of capitals.
Bourdieu (1987, p. 4) defines symbolic capital as “the form that the various species of capital assume when they are perceived and recognized as legitimate.” While social and symbolic capital are inherently “very strongly correlated” (Bourdieu 1987, p. 4), Bourdieu (1986, p. 49) also postulates that the “transmission and acquisition” of cultural capital “are more disguised than those of economic capital” and that “it is predisposed to function as symbolic capital.” By this, he refers to cultural capital often not being recognized as capital, but as “legitimate competence, as authority exerting an effect of (mis)recognition.”
Integrating symbolic capital into a conceptualization of health capital could allow for a more nuanced understanding of the rationale behind individual practices of healthcare. Participation in an online health community could not only be viewed as a matter of obtaining social support but also as a quest for being recognized as legitimate sufferers. Expertise by experience could be understood not only in terms of accumulation of relevant health knowledge but also as a means of social distinction within the relevant social structures. Consuming superfoods, expensive training shoes, carbon fiber bicycles, luxury wearables for self-tracking, and the services of personal trainers could be seen as driven by a desire for social distinction and, ultimately, status rather than as an investment in physical well-being. In this spirit, healthism as a neoliberal project and a state ideology on the societal level could be nuanced by an understanding of the agents’ quest for social distinction not only the social field of health but also in other fields.
Symbolic capital could also help to understand seemingly contradictive and even counterproductive practices. For some young men, status based on perceptions of masculinity outcompetes concerns for health, reducing their interactions with health services (Gough 2006). For similar reasons, middle-aged men routinely and purposively damage their joints and actively increase their risk of cardiovascular diseases by training for and competing in marathons (Schwartz et al. 2014). Likewise, women exhibit a fair share of self-destructive behaviors such as eating disorders and exercise addiction (Lichtenstein et al. 2017) in their quest for the “perfect body” and the status that this ideal conveys.
Embracing a Bourdieusian perspective, this article proposes to conceptualize health capital as the aggregate of the actual or potential resources possessed by a given agent that have the capacity to affect the position of agents in the social field of health. Health capital encompasses the field-dependent skills, competencies, social relationships, financial means, and status that can, immediately or mediated through conversion from other forms of capital, be employed toward the preservation of good health and the management of illness. It, thus, draws upon the synergy of and complements economic, social, cultural, and symbolic forms of capital. In the remainder of this article, unless explicitly otherwise noted, the term “health capital” will refer to this conceptualization.
Such a Bourdieusian conceptualization of health capital appears to be potentially most fruitful in understanding the construction of individual health as it allows transcending the input–output-oriented production focus of human capital theory by emphasizing the causal and human relations underlying individual healthcare practices. The following sections will use this perspective to explore and discuss the efficacy, the legitimation, and the proper place for health capital through reflection on socially and culturally embedded mass-cultural trends in the increasingly complex and individualized social field of health.