Structural Explanations

The social model of health looks at the social, economic and political systems or structures for an explanation of illness and premature death.

1. People have been aware of this perspective for a long time, as the

following quotes show. The first writer, John Hewetson, is commenting just after the end of the Second World War in 1946. Think of the link between his ideas and the moral sense of ‘equity’ (the idea that these things are preventable and unnecessary) that we looked at in Part 1 of the course.

“...Poverty is still the lot of millions, and attendant upon it comes sickness, lowered health and premature death. Yet if one permits one’s imagination to fill in the details, to try and picture the amount of pain and misery and frustration caused by ill-health, one’s anger at the society which creates

and permits such a volume of suffering is almost stifling.  Nevertheless, the situation has its favourable aspect. Anger is called forth because the misery and ill-health caused by poverty are preventable.  If preventable, one can say like the English King, why not prevented?  For with the resources which men call on today, there is abundance in the world for everyone, and poverty could be completely eradicated.”

2. A book written by researchers at the University of Edinburgh in 1989 emphasised their view that focusing on individual behaviour for the cause of health problems was misplaced.

“...Although there do exist voices of dissent, health professionals, policy makers and politicians have largely succeeded in promoting the view that individual behaviour is both the prime cause of ill health and a major factor in the maintenance and attainment of good health...”

“The authors believe that public health is about social systems and collective decision making rather than being exclusively about the isolated activities of individual members of the public”.

3. Community Food and Health Scotland in their ‘Fruitful Participation’ report (2007) go further than this in highlighting how actually becoming involved can have positive impacts on health and make for better outcomes all round:

“ … getting people involved in decision-making around food and health issues can be enjoyable, democratic, empower those involved and make a difference.”

“Getting people involved does mean that projects and activities are more likely to work. Getting people involved in food and health improvement activities in their groups or in their communities, as opposed to ‘parachuting’ solutions into an area, means that a project is more likely to be successful.”


Individual Explanations

In the nineteenth century there was a view that ill-health was a result of moral failure and lack of a proper sense of responsibility.

This meant that you became ill because you had done something wrong.  We can see this view put forward today.

1. In 1977 in the journal Science, John Knowles wrote a much quoted article called ‘The Responsibility for Health’.  He stresses the individual’s responsibility with strong moral overtones:

“...prevention of disease means forsaking the bad habits which many people enjoy - overeating, too much drinking, staying up at night, engaging in promiscuous sex, driving too fast and smoking cigarettes - or put another

way, it means doing things which require special effort - exercising, improving nutrition, going to the dentist, practicing contraception, ensuring harmonious family life and submitting to screening examination”.

A view pretty much repeated by the then Health Secretary Andrew Lansley in 2010


2. Edwina Currie, the UK Under Secretary for Health in 1986, caused a great deal of debate when she was quoted as saying that the best way to tackle ill-health among the people was by:

“...impressing on people the need to look after themselves better...” She suggested that old people who suffered from hypothermia could knit themselves more warm clothing and that the diet of chips in the north of England was the cause of such poor health.

3. Many current health messages concentrate on changing your lifestyle to become healthier. The following quote from a modern health promotion leaflet reflects this individual approach:

“...It’s never too late to start looking after your health. You can reduce your risk of heart disease by making a few simple changes.”

Although there is some truth in this, it does not mention other factors which could lead to heart disease - stress, working or housing conditions etc - factors which are often outwith the individual’s control.

Sometimes people refer to this as ‘victim blaming’ - that is blaming the individual who is already suffering by suggesting that their illness is their own fault. As we saw in the unit on Powerlessness the trouble is that people begin to believe this - they internalise this - and feel it really is their fault.




(Based on a case study supplied by Community Food and Health Scotland – 2009)

Clydesdale Community Food Market is a community co-op selling fresh fruit and vegetables in two villages in rural South Lanarkshire – Rigside and Kirkmuirhill. We are supported by Healthy Valleys (Healthy Living Centre), in partnership with Integrated Children’s Services and NHS Lanarkshire.

The market started in June 2008 and has now been operating for over one year! We sell fresh fruit and vegetables on one morning per week in two rural communities where there are significant levels of deprivation. We also supply fruit to nurseries in four local villages.

In one of these communities there is only one shop. This is a small convenience store which sells only very limited amounts and types of fresh produce with little choice and prices which are not competitive. In the other village, whilst there is already some availability, it is highly priced and again, choice can be limited. Alternatives to local shops are in Lanark which is 8 miles from Rigside but public transport is infrequent and expensive.

Healthy Valleys has recruited volunteers to run the food market and has provided the training they needed to do so.  In the first year of operation, this has involved 14 volunteers in training in a wide range of areas such as food hygiene, customer service, health promotion, volunteer procedures, health & safety and retail law to name but a few. In the last few months volunteers have also attended additional food handlers and manual handling courses as well as computer training and committee skills courses in preparation for becoming a constituted group in our own right. We are now known as Clydesdale Community Food Market.

Clydesdale Community Food Market has always aimed to be a health promoting organisation and a vehicle for enabling local people to benefit and improve their health and lifestyles. The following health promotion activities have been undertaken within the food market over the course of the first year:

•  Braveheart Nurses attended both venues and offered health checks

•  Consultation activities for early intervention activities feeding into the ‘Grassroots’ project

•  Involvement in Health Promoting Schools events with local primary schools

•  Promotion of healthy eating through the local High School

•  National Smile Month event

•  Poster campaigns for Breast Cancer Awareness, Alcohol awareness etc.

•  Proposal to have smoking cessation drop-in running alongside the food market in the future

•  Health Promotions Officer in regular attendance distributing health information leaflets and guiding individuals to sources of assistance where required.

Since we first started, the volunteers have been trained and we have become more professional in what we do, we have even started to wear a uniform and name badges in the markets.

We have learned a lot about seasonality and now promote produce that is in season. We are also more aware of our carbon footprint and want to source more of our produce locally.

Our future plans are for the group to operate and develop as an independently constituted group although Healthy Valleys will still support our volunteers.

Sustainability is the big challenge. The Market broke even in 2007-08, but mainly due to initial start-up funding. Increasing the customer base via various marketing initiatives and also finding someone who could consistently make use of surplus produce would make a big difference.

Transport for volunteers and produce is an issue and we are currently looking to recruit volunteer drivers.

We are also looking to run Smoking Cessation groups on a drop in basis alongside the Food Market and also market national health promotion campaigns amongst customers.

What advice would we give to others?

Get support

We have had a lot of support from “Lanarkshire Food and Health Partnership” whose expertise and practical input has been invaluable. Further support and advice from them and “Growing Better Together” helped us identify the legal obligations and demonstrated admirably what potentially could be achieved over time.

Check out the legal requirements

You can’t just use any weighing scales and there are regulations about how you display prices and country of origin information.

Try to plan ahead to avoid issues that could come up: For example:

Transport is a problem in our area and we maybe didn’t think enough about how we would move people and produce between venues. Also, cardboard disposal has proved to be one of our biggest headaches and a year on, our arrangements are still a bit fragile.




(Based on a case study supplied by Tina Burgess (Western Isles Health Board) This project was funded by NHS Health Scotland as one of the pilot projects

“Health Inequalities in Mental Health and Well Being in Later Life”. The Health Promotion Specialist for Health Inequalities submitted the successful bid in partnership with the Cearns Community Development Project (CCDP). The identification of need for the pilot was taken from existing findings ranging from the first Cearns Health Needs Assessment (1996), and more recent community consultations. The reports highlight the need for developing creative avenues to increase the confidence and employability of the most vulnerable groups in our communities.

The main aim of the programme is to address health inequalities relating to mental well-being through practical activities around healthy eating and social excursions. The target group are older men under 65 years of age who have addiction and mental health issues. Key organisations who support the programme are the Apples and Pears Café - Board of Directors, Western Isles NHS Board Health Promotion Department, The Older Peoples Partnership, Hebrides Alpha Project, Lifestyle and the Alcohol and Drug Addiction Team.

Local volunteers and CCDP Community Development staff based in the Cearns commenced with the service in August 2007 which provided a lunch time drop- in meal provision service including a “hot soup takeaway in a flask”. On average over 18 males regularly use the service, and due to the success and identified need of this group the service has increased its meal service to 3 days a week and includes a “take away” provision for those not able to attend in person. Several escorted social transported walks are one of the highlights of the programme with over 8 men taking part in the walks around the island led by the Path to Health, Walk Hebrides Scheme.

The project has provided an insight into the physical and social needs of the group and in addressing social isolation within the wider community. There is clear evidence of a strong sense of belonging and recognitions of the care and understanding that exists for each other’s welfare within this community. The group have now taken over the ownership of the scheme and this has also led to a recognised increase in community involvement and participation.

Overall feedback from the group has been very positive and the initial evaluation report has identified “Cove’s Kitchen” as having one of the most uniquely innovative approaches to community led health initiatives.



1. What are the key things you have learned today about the differences between individual and structural explanations of health?


2. List some of the actions communities can take to address issues about healthy eating and access to food. Identify particular ideas that you feel would work in your community.


3. How did you find the session today?


4. How did you feel you contributed to today’s session?


5. Do you feel you have any particular strengths or areas for improvement?