Cultural capital and social inequality in health.
ABSTRACT Economic and social resources are known to contribute to the unequal distribution of health outcomes. Culture-related factors such as normative beliefs, knowledge and behaviours have also been shown to be associated with health status. The role and function of cultural resources in the unequal distribution of health is addressed. Drawing on the work of French Sociologist Pierre Bourdieu, the concept of cultural capital for its contribution to the current understanding of social inequalities in health is explored. It is suggested that class related cultural resources interact with economic and social capital in the social structuring of people's health chances and choices. It is concluded that cultural capital is a key element in the behavioural transformation of social inequality into health inequality. New directions for empirical research on the interplay between economic, social and cultural capital are outlined.
- SourceAvailable from: Kenneth Chambaere[show abstract] [hide abstract]
ABSTRACT: Educational attainment has been shown to influence access to and quality of health care. However, the influence of educational attainment on decision-making at the end of life with possible or certain life-shortening effect (ELDs ie intensified pain and symptom alleviation, non-treatment decisions, euthanasia/physician-assisted suicide, and life-ending acts without explicit request) is scarcely studied. This paper examines differences between educational groups pertaining to prevalence of ELDs, the decision-making process and end-of-life treatment characteristics. We performed a retrospective survey among physicians certifying a large representative sample of Belgian deaths in 2007. Differences between educational groups were adjusted for relevant confounders (age, sex, cause of death and marital status). Intensified pain and symptom alleviation and non-treatment decisions are more likely to occur in higher educated than in lower educated patients. These decisions were less likely to be discussed with either patient or family, or with colleague physicians, in lower educated patients. A positive association between education and prevalence of euthanasia/assisted suicide (acts as well as requests) disappeared when adjusting for cause of death. No differences between educational groups were found in the treatment goal in the last week, but higher educated patients were more likely to receive opioids in the last day of life. There are some important differences and possible inequities between educational groups in end-of-life decision-making in Belgium. Future research should investigate whether the found differences reflect differences in knowledge of and adherence to patient preferences, and indicate a discrepancy in quality of the end of life.BMC Public Health 11/2013; 13(1):1055. · 2.08 Impact Factor
- [show abstract] [hide abstract]
ABSTRACT: As intuitive and inviting as it may appear, the concept of patient-centered care has been difficult to conceptualize, institutionalize and operationalize. Informed by Bourdieu's concepts of cultural capital and habitus, we employ the framework of cultural health capital to uncover the ways in which both patients' and providers' cultural resources, assets, and interactional styles influence their abilities to mutually achieve patient-centered care. Cultural health capital is defined as a specialized collection of cultural skills, attitudes, behaviors and interactional styles that are valued, leveraged, and exchanged by both patients and providers during clinical interactions. In this paper, we report the findings of a qualitative study conducted from 2010 to 2011 in the Western United States. We investigated the various elements of cultural health capital, how patients and providers used cultural health capital to engage with each other, and how this process shaped the patient-centeredness of interactions. We find that the accomplishment of patient-centered care is highly dependent upon habitus and the cultural health capital that both patients and providers bring to health care interactions. Not only are some cultural resources more highly valued than others, their differential mobilization can facilitate or impede engagement and communication between patients and their providers. The focus of cultural health capital on the ways fundamental social inequalities are manifest in clinical interactions enables providers, patients, and health care organizations to consider how such inequalities can confound patient-centered care.Social Science [?] Medicine 09/2013; 93C:113-120. · 2.73 Impact Factor
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ABSTRACT: While empirical evidence continues to show that people living in low socio-economic status neighbourhoods are less likely to engage in health-enhancing behaviour, our understanding of why this is so remains less than clear. We suggest that two changes could take place to move from description to understanding in this field; (i) a move away from the established concept of individual health behaviour to a contextualised understanding of health practices; and (ii) a switch from focusing on health inequalities in outcomes to health inequities in conditions. We apply Pierre Bourdieu's theory on capital interaction but find it insufficient with regard to the role of agency for structural change. We therefore introduce Amartya Sen's capability approach as a useful link between capital interaction theory and action to reduce social inequities in health-related practices. Sen's capability theory also elucidates the importance of discussing unequal chances in terms of inequity, rather than inequality, in order to underscore the moral nature of inequalities. We draw on the discussion in social geography on environmental injustice, which also underscores the moral nature of the spatial distribution of opportunities. The article ends by applying this approach to the 'Interdisciplinary study of inequalities in smoking' framework.Sociology of Health & Illness 12/2013; · 1.88 Impact Factor
2008;62;e13 J Epidemiol Community Health
Cultural capital and social inequality in health
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on 6 February 2009
Cultural capital and social inequality in health
Professor Dr T Abel, University
of Berne, Switzerland, Institute
of Social and Preventive
Medicine, Division of Social and
Behavioural Health Research,
Niesenweg 6, 3012 Berne/
Accepted 3 September 2007
Economic and social resources are known to contribute to
the unequal distribution of health outcomes. Culture-
related factors such as normative beliefs, knowledge and
behaviours have also been shown to be associated with
health status. The role and function of cultural resources
in the unequal distribution of health is addressed. Drawing
on the work of French Sociologist Pierre Bourdieu, the
concept of cultural capital for its contribution to the
current understanding of social inequalities in health is
explored. It is suggested that class related cultural
resources interact with economic and social capital in the
social structuring of people’s health chances and choices.
It is concluded that cultural capital is a key element in the
behavioural transformation of social inequality into health
inequality. New directions for empirical research on the
interplay between economic, social and cultural capital
Material as well as non-material resources have
been found to be associated with population health
and risk of disease.1–4Studies on such resources that
are typically connected to an individual’s social
position, namely financial means and interpersonal
support, oftendraw on theories
Measures of economic and social capital have been
used successfully in health research.5–8Today,
income, as a key indicator of economic capital,
continues to be associated with health and risk of
instance through membership in support-providing
networks, has been shown to be associated with
health outcomes.11–13Recently, however, empirical
studies have appeared linking health inequality to
cultural capital,14 15and have argued that culture-
based activities, knowledge and perceptions pre-
sent a unique form of health-relevant capital.
However, the contribution of those studies to the
current discourse in social epidemiology remains
limited for two reasons. First, they lack a specific
definition of health-relevant cultural capital. Yet,
such a definition appears mandatory for mean-
ingful measurement of cultural capital in empirical
studies on health inequalities. Second, regarding
the multidimensional effects of social inequality,2 4
most studies attempt to filter out the unique
contribution of culture-based factors by statistical
approaches can, however, be criticised for neglect
of the more complex interactions between cultural,
social and economic capital. In an attempt to close
this gap, the present paper starts with a short
summary of the findings from recent studies
resources and health inequalities. Drawing on
Pierre Bourdieu’s original notion of cultural capi-
I then lay out those properties and
functions of cultural capital that are instrumental
in specifically addressing health inequalities. The
paper adds to the emerging literature on cultural
capital a theoretically derived definition of health-
relevant cultural capital and illustrates the role of
capital interaction in the social reproduction of
CULTURAL CAPITAL IN HEALTH RESEARCH
The general term ‘‘capital’’ refers to resources
generated by labour. Cultural capital can be
broadly defined as people’s symbolic and informa-
tional resources for action.18Those resources (eg
values, behavioural norms and knowledge) are
acquired mostly through social learning, with
learning conditions varying across the social
classes, status groups or milieus.19
The concept of cultural capital has gained
increasing attention in the social sciences19 20with
applications in health research recently emerging.
Veenstra21exploring relations between social space,
social class and health inequalities used measures
of economic, social and cultural capital. Familiarity
with various sport figures, artists, novelists and
books, and magazines were included in correspon-
dence analyses as indicators of cultural capital.
Linking cultural, social and economic capital
variables he was able to identify distinct social
spaces within which different health indicators
could be situated. To study the direct effects of
cultural capital on health outcomes, Khawaja and
Mowafi15examined associations between cultural
capital and psychosocial health. They found that
participation in cultural activities (ie reading
books, volunteering for cultural events) was—net
of the effects of socioeconomic status (SES) and
social capital—a powerful predictor of self-per-
ceived health among Lebanese women living in
poor urban communities. Malat14discussed the role
of cultural capital (eg patients’ beliefs about their
care, perceptions of physicians’ behaviours) in
racial disparities in medical treatment, suggesting
that ‘‘... non-whites are more likely to have a need
to activate cultural capital’’ (p 310) to secure better
treatment outcomes. In a particular medical
setting, namely treatment of allergic contact
dermatitis, Noiesen et al22studied the resources
needed by patients to understand medical advice
and to adopt appropriate behaviours. From their
findings they concluded that cultural resources
such as the capacity for active information seeking
and critical consumer behaviour contributed sig-
nificantly to the explanation of social class
research, a number of studies looked at participa-
tion in cultural events and culture-oriented leisure
activities.23–25Results from those studies suggest
Theory and methods
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on 6 February 2009
that participation in cultural activities is associated with lower
mortality risk and perceived health.
Overall, the findings from these studies indicate that culture-
based resources may play a significant role in the unequal
distribution of health. Yet, a closer look reveals some
methodological weaknesses and theoretical shortcomings. For
instance, the relevance and validity of indicators such as ‘‘hours
of TV consumption’’15or ‘‘frequency of theatre visits’’25as
meaningful indicators of cultural capital needs to be critically
discussed. Moreover, indicators such as participation in—often
costly—cultural events or TV consumption in poor countries
may both be highly related to peoples’ social class position and
thus their economic resources and social relations. Those
associations pose challenging questions and make it necessary
to explain the genuine meaning of cultural capital beyond the
well-known effects of economic and social resources on health.
Moreover, the associations between specific cultural resources
and economic and social capital clearly warrant further
CULTURAL CAPITAL: ITS PROPERTIES AND FUNCTIONS
RELATING TO HEALTH INEQUALITIES
Cultural capital refers to the operational skills, linguistic styles,
values and norms that one accrues through education and life-
long socialisation.17 20It comprises people’s social abilities and
competence for action, including their perceptions, values,
norms, cognitive and operational skills.16 26Cultural capital
emerges in three different forms: incorporated (e.g. values, skills,
knowledge), objectivised (eg books, tools) and institutionalised
(eg educational degrees, professional titles) cultural capital.17
Applied to health research, Bourdieu’s general notion of
cultural capital can be used to define health-relevant cultural
capital as comprising all culture-based resources that are
available to people for acting in favour of their health. In its
incorporated form it comprises health-related values, beha-
vioural norms, knowledge and operational skills. For instance,
health literacy—a resource for health-promoting behaviours
that is known to be unequally distributed across educational
classes27 28—can be explained as part of people’s incorporated
cultural capital. Also, behavioural norms and preferences that
were linked to health in the studies mentioned above can be
explained as incorporated cultural capital. For example, associa-
tions between attendance of cultural events and survival
outcomes23may partly be because those cultural activities are
part of distinct and often healthier lifestyles. Moreover, cultural
activities may promote feelings of belonging or activate other
health resources such as social support. Effects related to social
distinction may also help to explain associations between TV
consumption and subjective health in a Lebanese urban setting,
as observed by Khawaja and Mowafi.15In social cultural
contexts where possession of a TV set is a privilege of the
‘‘well off’’, TV consumption may promote psychological well-
being and increase individuals’ subjective health.
Health books and internet access (as sources of health
knowledge) or recreational equipment (eg for physical activity)
represent examples of objectivised cultural capital closely linked
to health and health-promoting behaviour. Outdoor exercise
equipment is a good example of objectivised cultural capital and
its functional and symbolic use: as Veenstra21observes, cycling
to work—in his study of Canadians in British Columbia a
typical middle-class lifestyle behaviour—is not only associated
with better health status through physiological processes
activated by the functional use of the bicycle. Objectivised
cultural capital (the helmet, the back pack, the rain gear) may
also ‘‘...induce social distance in every day interaction by
providing subtle messages to members of other classes to ‘keep
their distance’ and ‘stay in their place’’.[21, p.30] Thus,
depending on a particular social cultural context the use of
these objects (bicycles and their ‘‘accessories’’) may serve both:
physical health and subjective well-being through physiological
effects and social distinction.
In the present paper I focus on incorporated cultural capital as
it is in this form that cultural capital becomes a key component
that links people’s social position with the behavioural aspects
of health inequality (for a separate discussion of objectivised
and institutionalised cultural capital in health promotion see
Incorporated cultural capital becomes directly relevant to
health through distinct lifestyle patterns.21Definitions of
health-relevant lifestyles have focused on collective patterns of
health behaviours and orientations.30 31Health lifestyle patterns
are developed by groups of individuals according to the material
and non-material resources available to them.32Cultural capital
in the form of health values, perceptions, health knowledge and
behavioural norms provides the non-material resources needed
to develop healthy lifestyle patterns and deal effectively with
health issues on an everyday basis. The fact that the acquisition
of cultural capital depends on the social class-specific learning
context19 20explains why the health resources that emerge from
it are also unequally distributed across the social classes. In that
sense cultural capital—expressed and effective through collec-
tive lifestyles—is not only a determinant of individual health,
but also a crucial component in the social reproduction of health
inequalities through social class-specific health lifestyles.21 33
CULTURAL CAPITAL: INTERACTIONS AND TRANSFORMATIONS
RELEVANT TO HEALTH
The interplay between the different forms of capital can be
understood as a basic principle operating in the processes that
lead to social distinction, inequality and the reproduction of
social class.34Economic, social and cultural resources are
correlated and feed on each other (see fig 1).
The different forms of capital can be converted as it is, for
example, the case when personal income (economic capital) is
used for advanced education (cultural capital). Interactions can
also include intergenerational transmission of capitals. For
instance, parents invest their financial resources in their
children’s higher education. Their children’s higher educational
status may later not only lead them to better paid jobs, but also
be instrumental in acquiring social capital, for example by
increasing their chances for membership in powerful networks.
The basic principle of capital conversion can also be applied to
issues of health inequalities. It suggests that cultural, social and
Three forms of capital.
Theory and methods
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on 6 February 2009
economic capital affect people’s health through distinct patterns
Cultural resources affect the use of economic capital for health!
Economic capital provides people with options, many of which
are relevant to their health: paying for medical services or
insurance plans, being able to afford to live in a health-
promoting, supportive and safe neighbourhood or having the
money to buy healthy, yet often more expensive food. These are
but three examples of how financial resources determine
people’s range of health-enhancing options. However, for people
when operating within a given economic frame of options,
cultural resources come into play. This is the case, for example
when health-related values and norms, perceptions and knowl-
edge guide people’s health lifestyle choices.35 36Whereas the
range of choices for health-relevant consumer goods is
dependent on financial means, cultural capital is of particular
importance for using those financial resources for specific
healthy choices. Nutritional behaviour and patterns of physical
activity may be referred to as two respective examples: values
attached to health, knowledge about health effects of certain
food products and norms that guide health behaviours are all
cultural resources that structure people’s preferences and
choices, including their eating and physical activity habits.
Economic capital approaches often fall short of elucidating
the social differences observed in those health behaviours that
cannot be explained by financial determination: unhealthy
patterns of consumption such as smoking, excessive eating or
drinking or sedentary lifestyles are in large parts more
determined by people’s norms and values than by insufficient
financial means. Income explanations alone provide no convin-
cing answers to questions on how unhealthy lifestyles have
become normative in different groups, milieus and social classes.
Referring to the above examples, it appears reasonable to argue
that cultural capital in the form of values, perceptions,
knowledge and behavioural norms is instrumental in the use
of economic resources for health gains.
Cultural resources affect social capital for health!
Social capital provides people with access to interpersonal
support systems that may, among other benefits, be helpful in
matters of personal health and community health action.37 38To
acquire social capital, to sustain and use it successfully, other
resources are needed. Financial investments in the form of
entrance fees or costs of socializing may be mandatory in some
cases, for example for membership in support groups and clubs.
However, beyond monetary resources, certain behaviours and
value orientations are expected from all those who want to
belong to social capital-providing networks.39 40Sharing similar
values, knowing how to approach other members properly, the
ability to use appropriate language and communication styles
are examples of non-material conditions and cultural techniques
required for people to enter those networks.
Once a member, cultural resources may also facilitate an
individual’s use of social capital for health gains. In the form of
shared values and operational skills cultural capital provides the
means to actively participate in and benefit from social capital
networks that offer interpersonal support in health matters.
What this suggests is that particular cultural resources are
mandatory in the acquisition and instrumental in the use of
health-effective social capital.
Economic and social resources affect cultural capital for health!
People’s chances to acquire health-effective cultural capital
increase with the availability of other types of capital. Economic
capital may be required, for instance, to participate in activities
that encourage or re-enforce health choices such as health
promotion events or sports club programmes. Money is often
needed to gain access to particular learning facilities and
programmes. Examples may range from buying health books
to attending health promotion classes or paying for personal
health internet tools or services. Social capital, on the other
hand, can also increase people’s chances to accumulate health-
relevant cultural capital, for instance through informal access to
health information, expert knowledge and advice. Memberships
in networks or social groups such as patient’s organisations,
neighbourhood initiatives and self-help groups have been found
to improve health knowledge.41 42Thus the acquisition of
health-relevant cultural capital is in major parts directly
dependent on the availability of other types of resources,
namely economic and social capital.
Figure 2 provides a visualisation of the links between social
inequality and health inequality focussing on behavioural
Relationships between health-related lifestyles and peoples’
social class or status have been described earlier.30 32 35 36 43Those
authors have argued that the chances to realise a health-
promoting lifestyle are closely tied to people’s social class and
status position. The new model presented here goes beyond this
general observation by identifying the resources that facilitate
health-promoting lifestyles. It provides the grounds to distin-
guish between health-relevant economic, social and cultural
resources and shows their integration within a broader pattern
of capitals available. The model suggests focusing on the
interplay between the three different forms of health-relevant
capital, including measures of cultural capital. Moreover, it
draws attention to the fact that the resources needed to select or
adopt specific health-relevant lifestyles emerge from the inter-
play between economic, social and cultural capital. In this
dynamic form social inequalities affect—through collective
behavioural variations—people’s health status and risks.
How can we explain the relationship between material and non-
material resources for health? The present paper has addressed
this question by focusing on cultural capital and its inter-
dependencies with economic and social capital. Health-relevant
cultural capital has been defined as the culture-based resources
that are available to people for maintaining and promoting their
health. Health values and norms, health knowledge and
operational skills have been identified as key elements of
health-relevant cultural capital. The possession of that form of
capital gains people health advantages whereas its acquisition
and use is tied to the availability of other forms of capital.
By explaining people’s culture-based health resources as parts
of their health-relevant capital, this approach places cultural
determinants firmly in the discourse of structurally based health
inequalities. Cultural capital is considered a non-monetary form
of capital that interacts with economic and social capital to
constitute people’s health chances and choices. As such, the
concept links structural and behavioural determinants of health
by explaining how people’s behavioural options and preferences
are constrained and structured by their cultural, social and
economic resources.31 35In health inequality research cultural
capital explanations can help to elucidate the translation of
social disadvantage into poor health.44It does so by identifying
Theory and methods
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on 6 February 2009
the resources behind the socialization processes that lead to
The theoretical considerations underlying the present focus
on the interaction between the different forms of capital have
significant implications for future empirical investigations.
Whereas the vast body of evidence on social health inequalities
led to concepts of ‘‘general susceptibility’’46and ‘‘fundamental
cause’’,47aetiological explanations seem to require a specifica-
tion of what particular form of social disadvantage leads to poor
health.48 49For measuring social disadvantage this means that
‘‘education, income and occupational class cannot be used
interchangeably as indicators of a hypothetical latent social
dimension’’.50On those issues the concept of cultural capital
provides a theoretically meaningful distinction between three
major forms of health-relevant capitals. Moreover, in its
attempt to account for the dynamic relations among the
different forms of health resources, the present approach
suggests to move beyond questions on the relative importance
of single social determinants of health, and explore the
relational effects among material and non-material health
resources. The guiding question for future theoretical and
empirical research would then become: how and under what
circumstances is the accumulation of and the interaction
between cultural, economic and social capital beneficial to
To realise the full potential of the cultural capital approach in
health inequality research some more work is needed. Extended
conceptual work is required to understand and integrate
other social factors involved, such as gender and ethnic
identity. Through cognitive and social learning processes,
incorporated cultural capital is invariably tied to the body of a
person.18Thus biological factors such as genetic dispositions and
physical conditions may also need to be considered in models
explaining the role of cultural capital in the unequal distribution
Of foremost importance for empirical investigations are the
development of valid and reliable indicators of health-relevant
cultural capital and the design of appropriate statistical models.
Recent attempts to operationalise cultural capital may provide a
helpful starting point. Theoretical guidance might be helpful to
move beyond the currently available indicators and develop
more comprehensive measures. In the present paper I have
described health-related values and norms, knowledge and
operational skills as key elements of health-relevant cultural
capital. Those should next be operationalised and applied as
indicators in empirical studies. Future statistical models need to
estimate the effects of cultural capital on health outcomes,
including interaction effects with other forms of capital. Also,
sophisticated multilevel models could be developed that help to
identify the social and biological factors that determine people’s
chances to acquire health-relevant cultural capital.
Acknowledgements: The author wishes to thank the colleagues who have provided
helpful comments on an earlier version of the manuscript.
Competing interests: None.
and health inequality.
Capital interaction, lifestyles
What this study adds
c This paper provides a theory-based definition of health-
relevant cultural capital and identifies health values and norms,
knowledge and skills as key elements of health-relevant
c A new focus in inequality research is suggested that explains
social inequalities in health as resulting from the unequal
distribution of economic, social and cultural capital.
c Interactions between the three forms of capital are described
as key processes in the social reproduction of health
Theory and methods
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on 6 February 2009
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