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

This journal article tackles the question of what structure means in the context of the structural influences on health equity. Understanding this concept and working to modify the impact is one of public health’s core goals.  Using tobacco smoking as the primary example, the authors examine the interactions between structural factors and health-related behaviours.  

From here, the authors propose a new conceptualization of structure, guided by the work of Pierre Bourdieu as well as Foucault’s notion of governmentality. The authors argue that any account of structure in public health must be consistent with three facts (p. 93): 

  1. Stark differences of attitude and behaviour exist within class positions.
  2. The power to influence these attitudes and behaviours does not lie solely with social class.
  3. There are certain discourses which are structurally pervasive but not determinative of behaviours.

To alter the current notion of structure, public health must make three changes (p. 95): 

  1. We must discard the idea that changing influences like income level will change individual health behaviours.
  2. We must explicitly acknowledge the limitations of our efforts to document influences on health.
  3. Epidemiological analysis must focus on differences within social groups, and similarities across social groups.


Use this resource to:

  • ground public health’s understanding of the structural influences in theoretical perspectives,
  • facilitate discussion about the meaning and understanding of structural influences on the social determinants of health, and
  • advocate for changes to epidemiological and research approaches to structural interventions.

Alignment with NCCDH work:

The concept of the social determinants of health has been around for many years and has been the focus of the NCCDH’s work. Recently, the field of public health has been describing other determinants of health — structural, political, moral and commercial, for example. Each of these deepens our understanding of one aspect of what impacts our health. The NCCDH is starting to explore these determinants of health, incorporating resources like this into our knowledge translation work. 

Let’s Talk: Redistributing power for health equity

Structural interventions that affect racial inequities and their impact on population health outcomes: a systematic review

Health equity frameworks as a tool to support public health action: A rapid review of the literature


See other resources on structural determinants of health.


Crammond, B. R., & Carey, G. (2017) What do we mean by ‘structure’ when we talk about structural influences on the social determinants of health inequalities? Social Theory & Health, 15(1), 84–98.

Tags: Structural determinants, Document, Journal Article