Cultural and Structuralist Approaches

To secure attention to the social determinants of health and build support for their strengthening, it is important to understand how social determinants of health come to influence health and cause disease. The very influential UK Black and The Health Divide reports considered two primary mechanisms for understanding this process: cultural/ behavioural and materialist/structuralist.^[78]

The cultural/behavioural explanation was that individuals' behavioural choices (e.g., tobacco and alcohol use, diet, physical activity, etc.) were responsible for their developing and dying from a variety of diseases. Both the Black and Health divide reports however, showed that behavioural choices are heavily structured by one’s material conditions of life. And—consistent with mounting evidence—these behavioural risk factors account for a relatively small proportion of variation in the incidence and death from various diseases. The materialist/structuralist explanation emphasizes the material conditions under which people live their lives. These conditions include availability of resources to access the amenities of life, working conditions, and quality of available food and housing among others.

The author of the Health Divide concluded: The weight of evidence continues to point to explanations which suggest that socio-economic circumstances play the major part in subsequent health differences.^[79] Despite this conclusion and increasing evidence in favour of this view, much of the Canadian public discourse on health and disease remains focused on “life-style” approaches to disease prevention.^[80]

These materialist/structuralist conceptualizations have been refined such that analysis is now focused upon three frameworks by which social determinants of health come to influence health.^[81] These frameworks are: (a) materialist; (b) neo-materialist; and (c) psychosocial comparison. The materialist explanation is about how living conditions – and the social determinants of health that constitute these living conditions—shape health. The neo-materialist explanation extends the materialist analysis by asking how these living conditions come about. The psychosocial comparison explanation considers whether people compare themselves to others and how these comparisons affect health and wellbeing.

In this argument individuals experience varying degrees of positive and negative exposures over their lives that accumulate to produce adult health outcomes.^[82] Overall wealth of nations is a strong indicator of population health. But within nations, socio-economic position is a powerful predictor of health as it is an indicator of material advantage or disadvantage over the lifespan.^[83] Material conditions of life determine health by influencing the quality of individual development, family life and interaction, and community environments. Material conditions of life lead to differing likelihood of physical (infections, malnutrition, chronic disease, and injuries), developmental (delayed or impaired cognitive, personality, and social development), educational (learning disabilities, poor learning, early school leaving), and social (socialization, preparation for work, and family life) problems.^[84][85]

Material conditions of life also lead to differences in psychosocial stress^[86] The fight-or-flight reaction—chronically elicited in response to threats such as income, housing, and food insecurity, among others—weakens the immune system, leads to increased insulin resistance, greater incidence of lipid and clotting disorders, and other biomedical insults that are precursors to adult disease.

Adoption of health-threatening behaviours is a response to material deprivation and stress.^[87] Environments determine whether individuals take up tobacco, use alcohol, experience poor diets, and have low levels of physical activity. Tobacco and excessive alcohol use, and carbohydrate-dense diets are also means of coping with difficult circumstances.^[88][89] Materialist arguments help us understand the sources of health inequalities among individuals and nations and the role played by the social determinants of health.