Keeping It Political and Powerful: Defining the Structural Determinants of Health

Abstract

Policy Points.

• The structural determinants of health are 1) the written and unwritten rules that create, maintain, or eliminate durable and hierarchical patterns of advantage among socially constructed groups in the conditions that affect health, and 2) the manifestation of power relations in that people and groups with more power based on current social structures work—implicitly and explicitly—to maintain their advantage by reinforcing or modifying these rules.

• This theoretically grounded definition of structural determinants can support a shared analysis of the root causes of health inequities and an embrace of public health's role in shifting power relations and engaging politically, especially in its policy work.

• Shifting the balance of power relations between socially constructed groups differentiates interventions in the structural determinants of health from those in the social determinants of health.

When the world health organization (who)’s commission on the Social Determinants of Health (CSDH) published their framework for the social determinants of health (SDOH) in 2010, they intentionally included two distinct concepts in their definition, “distinguishing between the mechanisms by which social hierarchies are created, and the conditions of daily life which then result.” ¹ The WHO continues to include both “the conditions in which people are born, grow, live, and age” and “the wider set of forces and systems shaping the conditions of daily life” in their definition. ² Perhaps responding to prior criticism, the CSDH explicitly called out changing the distribution of power as central to addressing the forces and systems that maintain inequity and was clear that engaging in this work is a political endeavor. ¹ , ³

Yet, almost immediately, many simplified the SDOH concept to include only the conditions of daily life. As part of Healthy People 2020, which was released in 2010, the US Centers for Disease Control and Prevention referenced the CSDH but defined the SDOH as the “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality‐of‐life outcomes and risks.” ⁴ As others have critiqued, this depoliticizes the concept of the SDOH ⁵ and is perhaps a result of dominant neoliberal worldviews in the United States and elsewhere. ⁶ Indigenous scholars and practitioners extend that critique, with a focus on the importance of decolonization, sovereignty, and self‐determination as key social determinants of their health. ⁷

With a new wave of attention to racial and health equity since 2020, public health researchers, practitioners, and funders have recognized that a focus on conditions is insufficient and have highlighted the need to focus on the structural causes—those closer to the root of inequities—and solutions. ⁸ , ⁹ This shift aligns with increasing—and contested—emphasis on addressing health equity, which itself is a term scholars define in various ways. Actionable definitions that move beyond a focus on conditions, such as the scholarship of Camara Phyllis Jones, describe health equity as the “assurance of the conditions for optimal health for all people. Achieving health equity requires valuing all individuals and populations equally, recognizing and rectifying historical injustice, and providing resources according to need.” ¹⁰ Common across these definitions is a call for shifting values, addressing injustice, and redistributing resources among other actions that target structural forces and mechanisms. ¹¹ , ¹² The CSDH defined structural mechanisms as “those that generate stratification and social class divisions in the society and that define individual socioeconomic position within hierarchies of power, prestige and access to resources” and named “structural mechanisms and the resultant socioeconomic position of individuals” as structural determinants. ¹ Yet, consistency about what can be categorized as structural is lacking, even as the use of the term appears to be growing.

In June 2023, we conducted a PubMed search for articles with the phrase structural determinants of health in their title or abstract and reviewed the 221 articles that were electronically available. The phrase first appears in a title or abstract in 2004 and was used approximately five to ten times per year between 2010 and 2019. Its use jumped fourfold in 2020, and in 2022, the phrase was found in 85 titles and abstracts. A quarter of the articles reviewed did not explain what they meant by the phrase. Only about 10% of the articles offered some definition. In the remaining approximately two‐thirds of the articles, the phrase was explained by listing examples of structural determinants, which varied from individual health‐related social needs such as housing and income to systems of power that undergird social hierarchy like racism and colonialism to instruments for creating and maintaining an unfair distribution of resources such as law and policies. Numerous iterations on the phrase structural determinants of health appeared, including structural drivers, structural forces, sociostructural determinants, and upstream structures. Many articles combined and/or conflated the concepts in defining the social and structural determinants of health.

When using the phrase structural determinants of health, articles most frequently cited the 2010 CSDH report, the National Academies of Sciences, Engineering, and Medicine 2017 Communities in Action report, the 2008 article by Marmot and colleagues, and the 2009 article by Farmer and colleagues. ¹ , ¹³ , ¹⁴ , ¹⁵ Two examples of definitions in retrieved articles include the following:

• “Structural determinants of health are the economic, cultural, political and social structures that shape the distribution of material and symbolic power and resources. In tandem with concerns for the health of the planet and ongoing legacies of colonialism and racism, these ‘structural drivers’ shape public policies across sectors creating predictable inequities in health and health‐promoting resources across and between nations and communities.” ¹⁶

• “Structural determinants of health are the social, economic and political mechanisms that generate and maintain social stratifications and, in turn, determine individual socio‐economic positions according to income, education, occupation, gender, race and ethnicity.” ¹⁷

Although there are some similarities in the definitions reviewed—the focus on the social, economic, and political dimensions of the structural determinants, for example—consistency is lacking across the published literature.

The phrase structural determinants of health is being used by many as though its meaning is self‐evident or to describe an abstract set of forces rather than as a concept with a specific definition and opportunities for measurement to track change. The word structural has become a buzzword, and the field of public health's lack of clarity about what we mean by structural and structural determinants of health is problematic. This ambiguity in phrasing and terminology allows those interested in virtue signaling but with no intention of supporting transformative change to co‐opt the language. As demonstrated in recent decades, this depoliticized use of terms creates confusion about their meaning and limits potential for transformative change. Herein lies a missed opportunity: a common definition and understanding of the structural determinants of health could help to identify actors who are and/or were involved and accountable and galvanize collective action, similar to how the common definition of SDOH encouraged cross‐sector collaboration to improve the conditions of daily life. A shared definition can make explicit that people and organizational partnerships taking strategic action together is required to advance health equity. Further, a definition that clarifies the essential components of the structural determinants of health, hypothesizes causal pathways, and reveals strategic intervention points can illuminate where and how effective actions—including work to change policies and specifically those that shift power relations—can advance health equity. Finally, a common definition is a starting place for informing research, generating evidence, and constructing measurement. A common definition identifies the necessary components whose presence or absence can be assessed in tracking change. Monitoring is an essential public health service, so it is critical that the field focuses on monitoring what matters for advancing health and equity.

We think, therefore, that the field must build from relevant theory to precisely and practically define structural determinants of health. The CSDH's work is now more than a decade old, and attention to and understanding of racial and health equity has evolved (and, in some cases, devolved). More recent papers that offer definitions (usually as incidental points) have not explained the underlying theories that support them, nor have they unpacked, in understandable terms, the complex concepts implicated in the social, economic, or political mechanisms or structures often cited as drivers of the unhealthy social conditions. A refined, clear, and common definition is the basis for clarifying key concepts and how they relate and therefore informs what is analyzed, prioritized, tracked, and targeted for intervention.

After reviewing insights from relevant theories about social structure and power, we offer such a definition of structural determinants and define its subcomponents. We then relate structural determinants back to power in order to further elucidate the concepts.

Selected Insights From Relevant Theory

Theory can help us move beyond a shared observation of unfair and unjust differences in the living conditions and health of populations to a shared analysis of root causes, who gains from or is accountable for health inequities, and how to make change. ¹⁸ We offer a brief overview of selected theoretical contributions that are relevant to arriving at a shared analysis of the ecosystem that influences health and a theoretically grounded definition of the structural determinants of health. These select insights are not a comprehensive synthesis but rather an invitation for critical reflection on an extensive body of literature on social structures, power, and what determines our health.

More than a decade ago, scholars including Krieger, Marmot and colleagues, and Wilkinson led theoretical thinking that informed the 2010 CSDH report. ¹⁴ , ¹⁸ , ¹⁹ The 2010 CSDH report named three main theoretical directions with overlapping focus to elucidate the pathways from structural and social determinants to population health and the distribution of disease. ¹ These include the following: 1) psychosocial—poor health resulting from real and perceived experience of personal status in unequal societies, 2) social production—economic processes and political decisions that shape material conditions and affect population health, and 3) ecosocial theory—historical and ecological dynamics that integrate social and biological factors to affect the embodiment and distribution of disease and social inequities in population health.

Expanding on this, we offer a subset of key concepts from sociology and political science literature to inform a definition of the structural determinants of health that can be relevant for practice. In summarizing the literature below relevant to power and social structures, we acknowledge that these concepts are inherently complicated, as they are not just a thing or a system but also a process, a relation, a patterned arrangement.

What Are Social Structures and How Durable Are They?

An array of theories from sociology and political science describe the concept of structures that shape our social worlds and create differential outcomes among socially constructed groups—groupings that we as a society have created based on perceived difference for the purpose of benefiting members of some of those groups. Young brought focus to the concept of structures as the relationships and interactions in a system that create patterns of behavior and outcomes. ²⁰ Social structures—structures that are socially created and maintained—influence how individuals experience their lives based on social position. According to Young, social structures are necessary to understanding forms of oppression, including exploitation, marginalization, and powerlessness. ²⁰ Social structures are constraining and self‐perpetuating forces of society, or durable patterned relationships, within which individuals can exercise free will.

Yet, scholars across fields have long theorized on the extent to which individuals or groups of people can, in fact, exercise free will and influence these durable, though not indestructible, patterned relationships that constrain change in our society. For example, Giddens's theory of structuration asserts that individuals have agency to act, but they operate within and replicate social structures through their actions in the form of the rules they make and how they distribute resources. ²¹ Other theorists have asserted that individuals internalize social structures, which they then act on in an iterative fashion. ²² In other words, people are influenced by social structures and act to recreate or challenge them, and this dynamic sets the pace and flow of change in our society.

Although social structures are durable patterned relationships, they are also changeable over time and place. Scholars have theorized on how social structures of a society reflect a history, produced over generations of actions and inactions by individuals and groups of people. ²³ As stated by Bourdieu, “The social world is accumulated history” with the “weight of the world” on social structures, making these structures barriers or bridges to individual and collective capacities and capabilities. ²⁴ , ²⁵ Similarly, the scholarship of Popay and colleagues explores how social structures are patterned across geography—how location and landscapes contribute to shared social meaning or “the ‘lived’ experience of place that shapes both individual and collective social action relevant to health.” ²⁶ These theories assert that different societies in different times and places collectively experience and cocreate different realities, influencing the possible actions of individuals within it. Further, the integrity and function of social structures are maintained by myriad actions and inactions of individuals and groups of people, transmitted through a historical, ideological, or political context. Simply put, although social structures are long‐lasting and difficult to change, people can alter existing social structures to create different relationships and outcomes over time and place.

How Do Social Structures Relate to Power in the Ecosystem That Influences Health?

Marx and many scholars since have viewed the concept of power (or power relations) as an essential characteristic of social structures, the capacity that both challenges and keeps those structures in place. ²⁷ Social structures are based on the interaction of individuals and groups of people, which can be understood as power relations. Power relations represent a continual struggle and negotiation in which actors draw on social, political, and economic resources to maintain or alter social constraints (i.e., structures). ²¹ , ²⁸ , ²⁹

Social structures and power relations are intimately intertwined in an ecosystem that is guided by, constrained, or reinforced through rules (laws, policies, or norms) and, importantly, their application through resource distribution or practices (budgets, governance, and institutional practices). This ecosystem becomes the arena for exercising power to make change in society. For example, Lukes's framework of three “faces of power” elucidates how power is exercised through the following: 1) decision‐making power in “exercising influence in the political or public arena and among formal decision‐making bodies to achieve a particular outcome,” 2) agenda‐setting power in “organizing the decision‐making environment, including who can access decision making and what issues are being considered by decision‐making bodies,” and 3) invisible power in “shaping information, beliefs, and worldviews about social issues.” ³⁰ , ³¹ With this view of power, we can understand that changing social structures requires the power to change decisions, agendas, and worldviews, shifting who ultimately has influence over the rules and their application.

These theories help to illuminate how individuals and groups of people can exercise power to change social structures, acting within those social structures, which limit or facilitate their ability to shape the material conditions of daily living, in turn, affecting our underlying biology, biological expression, and variation in population health. Based on these theories, which provide insights into who is implicated and how health is influenced, we now turn to defining the structural determinants of health.

Defining Structural Determinants of Health

The structural determinants of health are 1) the written and unwritten rules that create, maintain, or eliminate durable and hierarchical patterns of advantage among socially constructed groups in the conditions that affect health, and 2) the manifestation of power relations in that people and groups with more power based on current social structures work—implicitly and explicitly—to maintain their advantage by reinforcing or modifying these rules.

The structural determinants include the following:

• values, beliefs, worldviews, culture, and norms

• governance

• laws, policies, regulations, and budgets

• institutional practices

that impact hierarchical patterns of advantage and power relations. ¹ , ¹³ , ³²

The structural determinants are derived from dominant societal values, beliefs, and worldviews; reflect our histories; and can dynamically adapt to perpetuate—or disrupt—historical patterns of advantage and disadvantage.

In the current context of the United States, the structural determinants of health enshrine and encode structural racism, White supremacy, neoliberal capitalism, cis‐heteronormativity, and other forms of oppression and othering. They perpetuate dominant narratives, such as the story that the United States is a postracial society or that an individual's success is solely a function of their own hard work, and cause racialized, class‐based, gendered, geographic, and other related inequities in outcomes observable at the population level.

For clarity, Table 1 contains definitions of subcomponents and key terms used above, summarizing existing scholarship. Note that these subcomponents are interrelated (e.g., institutional practices are influenced by values, beliefs, culture, and norms) and have reciprocal relationships (e.g., social structures influence values, and values shape our current social structures). These terms have also sometimes been used interchangeably (e.g., determinant and condition).

Table 1.

Definitions of Terms Relevant to a Common Definition of Structural Determinants of Health

Term(s)	Definition
Determinant	“Any factor that brings about change in a health condition or other defined characteristic.” 33
Condition	Factors and circumstances that affect the health and well‐being of a particular community or group of people living in a particular area.
Values and beliefs	Values are “culturally defined standards held by human individuals or groups about what is desirable, proper, beautiful, good, or bad. Values serve as broad guidelines for social life.” Beliefs are “shared ideas held by a collective of people within a sociocultural system.” 34
Worldview	A conscious or unconscious conception of society based on our values, beliefs, and assumptions that shapes how we make sense of the world and our collective senses of responsibility and possibility. 35
Culture and norms	“Culture refers to the shared beliefs, values, practices, behaviors, and artifacts that characterize a group or society. Norms, on the other hand, are the unwritten rules or expectations that guide and regulate behavior within a particular cultural or social group.” 36
Governance	The “system of values, policies, and institutions by which society manages economic, political, and social affairs through interactions within and among the state, civil society and private sector. It is the way a society organizes itself to make and implement decisions.” 37 Governance can take many forms, including democratic and authoritarian models. Governance is also “the process of decision‐making and the process by which decisions are implemented (or not implemented). Governance can be used in several contexts such as corporate governance, international governance, national governance and local governance.” 38
Laws, policies, regulations, and budgets	Instruments used by governments and both public and private organizations to achieve their objectives and shape context and behavior. They establish rules and regulate activities in various sectors of society. A law is “a binding custom or practice of a community: a rule of conduct or action prescribed or formally recognized as binding or enforced by a controlling authority.” 39 A policy is “ a definite course or method of action selected from among alternatives and in light of given conditions to guide and determine present and future decisions.” 40 A regulation is “a rule or order issued by an executive authority or regulatory agency of a government and having the force of law.” 41 A budget is “a plan for the coordination of resources and expenditures.” 42
Institutional practices	“[T]he ways in which an institution's members carry out their functions and responsibilities, often through established patterns of behavior, procedures, and rules. They can include decision‐making processes, communication protocols, performance evaluations, hiring and promotion practices, and resource allocation.” 43

Across these definitions of terms, there are common themes relating to the processes, instruments, and practices at play within a value‐laden context—meaning they require actions in contested arenas, making them inherently political, for politics is defined as “the activities associated with the governance of a country or other area, especially the debate or conflict among individuals or parties having or hoping to achieve power.” ⁴⁴ These definitions make clear that changing the structural determinants of health requires political, though not necessarily partisan, engagement.

Emerging Definitions and Frameworks Relevant to “Structure” and “Determinant”

Several frameworks characterizing various types of determinants of health have emerged in recent years, including political, legal, moral, and commercial determinants of health. ⁴⁵ , ⁴⁶ , ⁴⁷ , ⁴⁸ Within the context of our definition, these represent subtypes of structural determinants of health and articulate the rules specific to those domains and how they are applied. For example, the commercial determinants of health framework ⁴⁸ includes discussion of: norms shaped by commercial interests; governance decisions such as privatization and deregulation; policies related to trade, housing, agriculture, and many other domains; and political, scientific, marketing, supply chain and waste, labor and employment, and financial practices. The commercial determinants framework includes explicit discussion of power imbalances and the patterned inequities that result from these drivers. These determinants of health frameworks are complementary to our definition of the structural determinants of health. Both can be useful in contextualizing and understanding the structural drivers and strategic interventions for advancing health equity.

Similarly, as noted above, the term “structural” has become more prominent in the determinant of health literature, including in reference to structural racism. Structural racism (as defined by Bailey and colleagues and Braveman and colleagues for example) is one type of structural determinant of health whereby the rules and how they are applied are structured among racialized populations and perpetuate the social construct of Whiteness as superior. ³¹ , ⁴⁹ Structural racism is established by and can be observed in the written and unwritten rules of US society, including, for example: beliefs in White supremacy, “law and order” worldviews, weak enforcement of environmental regulations that result in environmental injustices, laws that limit voter participation, and practices that overpolice communities of color. Structural racism intersects with other systems of power (e.g., sexism, classism, and ableism) and creates durable patterns of health outcomes that are unfair, avoidable, and unjust. ¹⁰ , ⁵⁰ , ⁵¹

Power and the Durability of the Structural Determinants of Health

The concept of power is essential to our definition of structural determinants of health. Power is what sets the rules and holds them in place. And, as the CSDH recognized, the shifting of power relations is required to change the rules—to make structural interventions on the durable patterns of advantage and disadvantage. ¹ Structural interventions can build the power of those who have been disenfranchised and marginalized by systems of oppression and limit the power of those who use it to maintain the oppressive status quo or increase inequity. ⁵² , ⁵³ Although there is not a clear line distinguishing structural determinants of health and SDOH, ¹³ shifting the balance of power relations among socially constructed groups differentiates an intervention in the structural determinants of health from one in the SDOH.

Interventions in the social or structural determinants operate distinctly. For example, it is possible to adopt policies that improve the conditions of daily life (intervention in social determinants) but not address the social processes or power imbalance (intervention in structural determinants) that influence the inequitable distribution of resources. Policies intervening on the social determinants, for example, neighborhood conditions, will have impacts mediated by the prevailing governance ideologies, fiscal policies, institutional practices, culture, and norms—targets of interventions in the structural determinants of health—and their potential impact may therefore be bounded. ⁵⁴

Figure 1 provides an example to further clarify this distinction. The interventions show a subset of those with impact on housing justice. Although housing is commonly understood to impact health and health equity outcomes, we focus on interventions that address health equity outcomes because, as others have pointed out, ⁵⁴ interventions that impact health in a universal manner may actually reinforce or increase inequities. The vertical scale represents the degree to which the intervention may shift the balance of power relations. We use the three faces of power framework as a guide. ³⁰ We consider interventions in the third face (invisible power) as having the potential for a broader impact on the distribution of power than interventions into the second face (agenda‐setting power)—successful interventions would impact more people and shift underlying worldviews, norms, and culture. In turn, interventions into the first face (decision‐making power) shift power more narrowly and interventions into the conditions of daily life even more so.

Figure 1.

Examples of Potential Interventions Into Structural and Social Determinants of Health Using Housing Justice as an Example and Guided by Lukes's Three Faces of Power Framework

Interventions across the social and structural spectrum are important; public health's work to provide services that address current health problems is critical, as are longer‐term initiatives that shift culture and values. We note that providing for people's basic needs is necessary for building power; people whose basic needs are met are more likely to have the time and ability to focus on participating in organizing initiatives. ⁵⁵ Interventions to address needs, conditions, and structures are also, by nature, intertwined. Passing a law that increases access to paid sick leave or paid family leave, for example, provides a foundation for more power building.

We can and must intervene across the spectrum of social and structural determinants of health. Attending to public health crises while also addressing underlying power imbalances requires an intentional strategy to make small shifts in public health practice for current interventions so that they do more to build power and facilitate future interventions that can shift power further. For example, public health interventions to provide shelter for people who are unhoused can also include a focus on connecting and organizing people around shared interests, in partnership with community organizing groups working on housing issues. This intervention can become a steppingstone for subsequent interventions into structural determinants, for example, those that involve people organizing to change laws or policies causing people to be unhoused. Interventions that can help shift the balance of power include advocating for policy change (e.g., policies related to unionization), influencing worldviews (e.g., worldviews related to what is considered valid knowledge and data), and building coalitions (e.g., uniting groups to advocate together for change).

Conclusion

The recent focus on the structural determinants of health is a critical step in advancing health equity. Extensive use of the term structural, combined with ambiguity about what it means, however, is likely to continue to depoliticize the term and reduce its value in focusing public health practitioners and researchers on the root causes of inequity. A refined, clear, and common definition of the structural determinants of health that directs actions to shift the balance in power relations can support a deeper understanding and fieldwide analysis of what it will take to advance health equity. Our proposed definition, for example, broadens public health's remit to include advocating for policy changes that shift power relations.

We recognize that definitions are but a starting place to bring about the change that is needed in public health practice and ultimately in realizing a society where all people and places thrive. Actions must follow—in an everpresent and increasingly complex political context in which governance hangs in the balance of contested spaces among individuals and political parties seeking power. History shapes the structures we exist within now, and each day, we build a history that we are collectively responsible for, whether we are intentional or not. We must acknowledge that doing nothing is in fact still an active contribution. People acting collectively have created the structures that cause inequity, and people acting collectively have the power to change those structures in ways that advance equity. The future of public health practice requires a focus on the structural determinants and for public health professionals to engage in power and politics undeniably.

Funding/Support

This work was supported in part by grant funding from the W. K. Kellogg Foundation and the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the funders.

Conflict of Interest Disclosures

No disclosures were reported.