OpenAI's Latest 4o Model Ranks Public Health Liberation Among Top Public Health Theories That Effectively Explain Health Inequities

These essays discuss 4o OpenAI's ranking of public health theories in effectively explaining health inequities. The first essay contained an attachment of the Public Health Liberation (PHL) manuscript - PHL ranking was #3. The second essay was the initial ranking results without the PHL manuscript - PHL ranking was #4. 

Essay 2 - Second Ranking (PHL Ranked #3)

Ranking Public Health Theories by Effectiveness in Explaining Health Inequities

Introduction

Public health theories differ widely in how well they explain health inequities – the systematic disparities in health outcomes across social groups. In general, frameworks that center structural, social, and power dynamics provide the most comprehensive explanations for why disadvantaged populations suffer worse health. As the World Health Organization’s landmark commission concluded, it is “factors in the social environment” – such as unequal distribution of wealth, power, and resources – that fundamentally shape health outcomes and access to care. By contrast, theories that focus narrowly on individual choices or biology tend to overlook these root causes, making them less effective for understanding inequities. Below, we rank a broad spectrum of public health theories from best to worst in terms of their effectiveness at explaining health inequities, with the strongest structural and equity-focused approaches at the top and the more individualistic or limited models toward the bottom.

(Note: The ranking is based on each theory’s ability to account for systemic drivers of disparities such as socioeconomic status, racism, gender inequality, and other forms of structural oppression. Citations are provided to support the evaluation of each theory.)

Top Tier: Structural and Equity-Focused Theories (Most Effective)

1. Social Determinants of Health (SDOH) Theory & Health Equity Frameworks

These frameworks emphasize that social, economic, and environmental conditions are the primary drivers of health outcomes, making them extremely powerful for explaining inequities. The SDOH approach, embraced by the WHO and others, argues that factors like poverty, education, housing, and discrimination “constitute the social determinants of health and are responsible for a major part of health inequities” within and between societies. In other words, unequal distribution of wealth, power, and resources – “a toxic combination of poor social policies and unfair economic arrangements” – leads directly to worse health in marginalized groups. Health equity frameworks build on this by providing practical guides to address those structural determinants in interventions and policy. For example, Dr. Margaret Chan of the WHO stated that while healthcare and lifestyles matter, it is social conditions that “determine access to health services and influence lifestyle choices in the first place”. Because they focus on the “causes of the causes” of disease (e.g. income inequality, racism, living conditions), SDOH-oriented frameworks decisively explain why health disparities persist and how to reduce them through systemic change. These approaches have essentially ended the debate on whether social factors matter – conclusively showing that improving social equity is key to closing health gaps.

2. Fundamental Cause Theory (Link & Phelan)

Fundamental Cause Theory (FCT) zeroes in on why health inequities stubbornly persist even as specific diseases or risk factors change over time. It posits that socioeconomic status (SES) and other forms of social advantage (like racism) are “fundamental” causes of disease because they grant access to flexible resources (money, knowledge, power, social connections) that protect health. This theory compellingly explains health disparities: those higher in social hierarchy can continually deploy resources to avoid illness (for instance, moving to safer neighborhoods or obtaining new treatments), whereas disadvantaged groups cannot. Link and Phelan famously demonstrated that as new health innovations emerge, people of higher SES adopt them more readily, maintaining a gap in outcomes. By identifying structural conditions (poverty, racial segregation, discrimination) as root causes, FCT helps explain why interventions targeting only proximate risks (diet, smoking, etc.) often fail to eliminate disparities – because the underlying inequities in resources and power remain. In short, inequity itself is pathogenic. FCT has become a foundational theory in public health disparities research because it highlights that we must tackle social and economic inequalities (the “fundamental causes”), not just individual behaviors, to achieve health equity.

3. Public Health Liberation (PHL) Framework & Theory of Health Inequity Reproduction

Public Health Liberation (PHL) is a comprehensive, transdisciplinary framework introduced in 2022 that explicitly aims to elucidate and dismantle the systemic drivers of health inequity. PHL reconceptualizes the “public health economy” as the interplay of political, economic, and social forces that produce health disparities. It integrates diverse theories (from critical race to political economy) and introduces new constructs – for example, the Theory of Health Inequity Reproduction (THIR), Public Health Realism, and the concept of the “Gaze of the Enslaved” – to describe how inequities are actively sustained and how they can be interrupted. THIR in particular provides a framework for understanding how powerful interests and institutions deliberately or inadvertently reproduce health disparities across generations, aligning with ideas of hegemony and structural violence. Notably, PHL is rooted in the perspectives of marginalized communities (the framework was largely authored by Black women with lived advocacy experience) and calls for community empowerment and systemic change. In a comparative analysis, PHL’s approach was found to be more innovative and inclusive than traditional health disparity models, by unifying philosophy, theory, and practice into a transformative vision for health equity. Because it explicitly critiques fragmentation in public health and centers the voices of the oppressed, PHL is extremely effective in explaining inequities and pointing toward liberation from them. It represents an emerging gold standard that not only diagnoses structural injustice but also advocates for radical changes (e.g. new power-sharing, “liberation safe spaces”) to achieve health justice.

4. Intersectionality Theory

Intersectionality provides a crucial lens for understanding complex health inequities by examining how multiple systems of oppression intersect to shape people’s health. Originally developed by Kimberlé Crenshaw in legal studies and now widely applied in public health, intersectionality recognizes that factors like race, gender, class, sexual orientation, disability, and others do not act independently – they interlock to create unique experiences of advantage or disadvantage. For example, the health challenges faced by a low-income Black woman cannot be explained by racism or sexism alone, but by their combined, intersecting impact. Intersectional analysis reveals how “intersecting systems of oppression – including structural racism, class/capitalism, patriarchy, heterosexism, ableism, and others – interact to produce major differences in embodied health” among people with different social identities. This framework moves beyond one-dimensional explanations (e.g. “racial disparities” or “gender disparities”) and instead highlights that overlapping inequalities (like being subject to both racial bias and gender bias) can amplify stress, limit access to resources, and ultimately worsen health outcomes. Intersectionality is thus highly effective in explaining why, for instance, women of color or LGBTQ+ individuals in poverty often experience some of the worst health statuses – they sit at the convergence of multiple oppressions. Moreover, intersectionality explicitly rejects “blaming the victim,” instead refocusing attention on power dynamics at individual, institutional, and structural levels. By doing so, it encourages public health scholars and practitioners to examine how combined power imbalances (racism and sexism and classism, etc.) drive health inequities, and to develop multifaceted solutions. In summary, intersectionality offers a rich, nuanced paradigm that captures the complexity of real-world health disparities and challenges us to address the interwoven nature of social injustice.

5. Critical Race Theory (CRT) & Anti-Racism Frameworks

Critical Race Theory and related anti-racism approaches center systemic racism as a root cause of health inequities, making them among the most potent explanatory frameworks, especially for racial and ethnic health disparities. CRT in public health examines how historical and contemporary racism – in policies, institutions, and cultural narratives – creates health-harming conditions for people of color. This perspective holds that racism is not just individual prejudice but is embedded in societal structures (e.g. residential segregation, discriminatory lending, unequal law enforcement) that lead to worse health outcomes in marginalized racial groups. For instance, racism restricts access to quality education, employment, housing, and healthcare for certain groups, which in turn drives higher rates of chronic disease and lower life expectancy. Researchers have noted plainly that “race and racism play a role in explaining health disparities”, beyond what individual behaviors or genetics can account for. Anti-racism frameworks in public health translate this analysis into practice by explicitly aiming to dismantle systemic racism through policy change, community engagement, and organizational transformation. They emphasize structural interventions (like reforming racist policies or reallocating resources to marginalized communities) over blaming “cultural” or individual factors. An approach known as “racial realism” (from legal CRT) further argues that racial inequities are deeply entrenched in society’s structure and therefore require realistic, structural remedies rather than superficial fixes. Overall, CRT and anti-racism approaches are highly effective in explaining inequities because they identify racism itself – a fundamental driver of unequal power and resources – as a public health crisis. By viewing health disparities through the lens of racial justice, these frameworks guide us to address root causes such as segregation, discrimination, and implicit bias in healthcare, rather than treating racial health gaps as mysterious or solely behavior-based. The result is a far deeper understanding of why, for example, Black Americans have higher maternal mortality or why Indigenous peoples suffer more chronic disease – and a call to action to eradicate the racist structures producing those outcomes.

6. Feminist & Queer Theories in Public Health

Feminist theory in public health focuses on how gender-based power imbalances and patriarchy produce health inequities, while Queer theory examines how heteronormativity and stigma against LGBTQ+ people harm health. These perspectives are invaluable for explaining disparities tied to gender and sexual identity. Feminist approaches highlight that women’s health is often undermined by social structures – for example, unequal gender roles leading to caregiving burdens, exposure to gender-based violence, wage inequality, and exclusion from power, all of which can translate into worse health outcomes for women. Feminist scholars point out that healthcare systems and research have historically been male-centric, often neglecting women’s experiences and specific needs. Thus, disparities such as inadequate pain management for women, higher rates of certain mental health issues, or inequitable access to reproductive healthcare can be traced to sexist biases and structural discrimination. Queer theory, on the other hand, draws attention to the health impact of society’s norms around sexuality and gender identity. It explains that LGBTQ+ populations experience unique health inequities (like higher rates of depression, HIV, or substance use) largely due to stigma, discrimination, and lack of inclusive care rather than intrinsic characteristics. For instance, policies and norms that assume everyone is heterosexual or cisgender often result in invisibility or poor access to appropriate services for LGBTQ+ people. Both feminist and queer theories share a critique of how dominant norms marginalize certain groups – women, sexual and gender minorities – and in doing so, they reveal mechanisms of health disparity (e.g. stress from discrimination, barriers to care, violence, economic marginalization). They also emphasize empowerment and representation: including women’s voices and LGBTQ+ perspectives in public health decision-making leads to more equitable health interventions. By framing health inequities as a result of patriarchy and heterosexism (among other forces), feminist and queer theories direct attention to correcting power imbalances – such as advocating for reproductive rights, addressing intimate partner violence, or ensuring gender-affirming healthcare – thereby powerfully explaining and addressing gaps in health outcomes.

7. Ecosocial Theory (Nancy Krieger)

Nancy Krieger’s Ecosocial Theory is a holistic, multilevel framework specifically devised to explain how social injustice becomes embodied as health inequity. It integrates social and biological factors by asserting that our bodies biologically incorporate the social and ecological context in which we live. The core idea is embodiment: people’s lived experiences of racism, poverty, pollution, etc., literally get “under the skin” to influence disease distribution. Ecosocial theory outlines constructs like pathways of embodiment, cumulative interplay of exposure and resistance, and agency/accountability. Crucially, it insists on examining history and power – how over the life course and across generations, macro-level forces (colonialism, policies, economic systems) create exposures and vulnerabilities for certain populations. One of its key assertions is that the social system that creates discrimination and inequalities is responsible for patterns of disease in society. This stands in contrast to purely biomedical or lifestyle explanations; instead of blaming individual behavior or biology, ecosocial theory holds the state and social structures accountable for health disparities. For example, it would trace a racial disparity in hypertension back to factors like chronic stress from racism and segregated neighborhoods (and demand that epidemiologists explicitly acknowledge such structural causes). By spanning from molecules to society and emphasizing interactions over time, ecosocial theory provides a sophisticated explanation of inequities. It accounts for why, say, low-income communities of color have higher disease rates – not due to innate differences, but because they endure layered exposures (poor housing, environmental toxins, violence, inadequate healthcare) that are products of structural inequality. Krieger even advocates that public health researchers adopt an explicit justice stance, becoming “activists, not just researchers, when faced with injustice”. This makes ecosocial theory not only explanatory but also aligned with addressing inequities at their roots.

8. Structural Violence & Structural Vulnerability Theories

Structural violence theory, a concept widely associated with physician-anthropologist Paul Farmer, explains health inequities as the result of “social structures that put people in harm’s way.” It describes how institutional and systemic forces (poverty, racism, sexism, political oppression) inflict injury on certain groups by depriving them of basic needs and opportunities. For instance, the excess of HIV, tuberculosis, or infant mortality in impoverished communities can be seen as a form of violence exerted by social arrangements that systematically disadvantage those communities. Farmer and others have shown that conditions like lack of access to clean water, education, or medical care are not random – they are the outcome of decisions and structures (colonial histories, capitalist economies, discriminatory laws) that consistently favor some and marginalize others. In this view, premature deaths and suffering among the poor are not just unfortunate outcomes but unnecessary harm resulting from injustice, essentially a kind of violence. The related concept of structural vulnerability zeroes in on how people’s position in social hierarchies (e.g. as undocumented immigrants, homeless individuals, or ethnic minorities) renders them vulnerable to illness or injury. It asserts that vulnerability is not an inherent trait but is produced by structural factors like legal status, economic exclusion, or stigma that constrain a person’s options and health. Both theories are highly effective in explaining health inequities because they shift the focus from individual behaviors to the “web of causation” rooted in societal structures. A striking illustration comes from Friedrich Engels, who in 1845 described how workers in brutal conditions were forced into “such a position that they inevitably meet an early and unnatural death” – calling it “social murder” by the ruling class. This early articulation of structural violence shows that when society places a group at severe disadvantage, the resulting ill health is a form of systemic harm. Today, viewing issues like high Indigenous suicide rates or Black maternal mortality through this lens highlights how historical trauma, racism, and poverty are structural assaults on health. By naming these conditions as violence, this theory underscores the moral imperative to reform the structures themselves (e.g. advocate for policy change and social justice) in order to prevent further harm.

9. Political Economy of Health (Marxist Theory)

The political economy of health approach (rooted in Marxist and critical social science) examines how economic and class relations under capitalism produce and pattern health inequities. This theory argues that health disparities are a byproduct of the same forces that drive wealth inequalities – namely, the exploitation and marginalization of certain classes and communities. It points out that under capitalist systems, those with economic power (elites, corporations) influence policies in ways that often prioritize profit over public health, leading to inequitable conditions. For example, inexpensive housing might be located in polluted industrial zones, or labor practices might expose workers (often low-income or migrant) to health hazards, all in service of profit. A classic reference is Engels’ observation that the English working class in the 19th century suffered high mortality because of wretched working and living conditions imposed by the capitalist order – essentially society was committing “social murder” by sacrificing workers’ lives for economic gain. Marxist-informed health theory also highlights how class struggle and power imbalances influence the distribution of resources like healthcare, nutrition, and safe environments. Those with wealth not only can afford better living conditions and care, but they also shape policy (for instance, resisting regulations that would improve worker safety or redistribute resources). Thus, the poor experience worse health largely because the system is organized to benefit the rich at their expense. This approach is very effective in explaining broad patterns such as why lower socioeconomic classes consistently have higher disease rates: it connects these patterns to structural factors like income inequality, labor exploitation, and lack of political clout among the poor. It also sheds light on global health inequities – for instance, how colonialism and global capitalism have left many low-income countries with weak health systems and impoverished populations. In sum, the political economy perspective exposes the “hidden” economic and political drivers of health inequity, aligning with the adage that “inequality is bad for our health.” It calls for addressing the capitalist and class-based structures (through policies like redistributive welfare, labor rights, universal healthcare) to achieve meaningful improvements in health equity.

10. Life Course Theory

Life Course Theory explains health inequities by looking at how advantages or disadvantages accumulate over an individual’s lifetime and even across generations. This approach posits that exposure to risk or protective factors at early life stages (fetal development, childhood, adolescence) can have lasting impacts on health trajectories. Crucially, life course models illuminate why people from marginalized groups often have worse health not just at one point in time, but throughout their lives. For example, children born into poverty or subjected to discrimination may experience poorer nutrition, heightened stress, and limited educational opportunities in childhood – factors that can lead to developmental setbacks or chronic physiological stress (such as elevated cortisol levels). These early disadvantages can set them on a path toward adult health problems (like higher rates of diabetes, hypertension, or mental illness). Furthermore, life course theory includes concepts like “critical periods” (when exposures have particularly strong effects, such as lead poisoning in early childhood affecting brain development) and “cumulative risk” (where repeated or long-term exposure to adversity has an additive or synergistic effect on health). It also meshes with intergenerational ideas – for instance, a mother’s malnutrition or high stress during pregnancy (often linked to her social disadvantage) can influence the baby’s health (low birth weight, etc.), thus passing on inequality-related health risks. The life course perspective is effective in explaining inequities because it shows how health disparities are produced over time, not just as snapshots. It accounts for phenomena like the racial “weathering” observed among Black Americans – the idea that chronic exposure to social adversity causes accelerated aging and earlier onset of illness in mid-life. It also clarifies why interventions must happen early: by the time disparities manifest in adulthood, they are the cumulation of decades of unequal experiences. In sum, life course theory enriches our understanding by connecting past and present – demonstrating that today’s health gaps often originate in childhood socioeconomic conditions, early-life trauma, or even historical events that place certain groups on a different life trajectory from the start. This underscores the need for policies that support children and families (e.g. reducing child poverty, combating childhood discrimination, early education), as these are ultimately health equity policies.

11. Historical Trauma Theory

Historical trauma theory is particularly potent for explaining inequities in populations that have faced collective traumas across generations, such as Indigenous peoples, African Americans, or other colonized and oppressed groups. It proposes that massive group trauma (like colonization, genocide, slavery, war, forced relocation or cultural suppression) can lead to psychological and health effects that are transmitted to subsequent generations. The mechanism might include learned behaviors, cultural disintegration, stress biology (e.g. epigenetic changes or chronic stress responses), and socioeconomic disadvantages that persist long after the original traumatic events. For example, many Indigenous communities today experience high rates of substance abuse, depression, suicide, and chronic disease. Historical trauma theory explains this as the legacy of colonization and forced assimilation, wherein the unresolved grief and stress of past generations (from land dispossession, boarding schools, etc.) continue to affect community well-being now. Essentially, populations can carry a “trauma burden” that contributes to health vulnerabilities. This theory is effective in explaining otherwise perplexing disparities, such as why American Indian/Alaska Native populations have faced persistently poor health outcomes: standard risk factors alone cannot account for these, but the context of historical oppression and intergenerational trauma offers a compelling explanation. It also applies to other groups – for instance, the intergenerational effects of the Holocaust on mental health of descendants, or how slavery and ongoing racism have led to a form of intergenerational trauma among African Americans. Historical trauma theory often overlaps with life course and psychosocial theories but extends beyond individual lifetime to collective, multigenerational time scales. It underscores the importance of context and history in public health: without addressing past injustices and their present-day echoes (for example, loss of cultural identity, community distrust of institutions, economic marginalization stemming from stolen resources), we cannot fully understand or remedy certain health inequities. This perspective pushes public health toward healing initiatives (like trauma-informed care, cultural revitalization, truth and reconciliation processes) as part of closing health gaps.

12. Critical Public Health & Critical Medical Anthropology

Critical Public Health and Critical Medical Anthropology are academic perspectives that critique mainstream public health approaches and instead emphasize the role of power, inequality, and social context in health. These perspectives operate with an explicit social justice lens. They argue that conventional public health can be too focused on technical solutions or individual behaviors, while ignoring how political and economic structures shape health. For example, a mainstream approach to obesity might emphasize personal diet and exercise, whereas a critical public health approach would ask: who has access to healthy food or safe spaces to exercise, and how do marketing, subsidies, or urban planning policy driven by corporate interests affect these conditions? Critical Medical Anthropology (CMA) in particular examines health through the lens of political economy, culture, and power. It looks at how global forces (like neoliberal economic policies or pharmaceutical industry influence) and local power relations (like class, ethnic, or gender hierarchies) affect illness and healthcare. CMA scholars often highlight the concept of medicalization (how social problems get framed as medical issues) and ideology (how health narratives can serve elite interests). For instance, CMA would critique a narrative that blames indigenous peoples’ poor health on “culture” or genetics, instead pointing to land loss, poverty, and marginalization as the real issues. Similarly, critical public health might call out how public health institutions themselves can perpetuate inequity if they are not inclusive or if they prioritize interventions that don’t upset the status quo. These frameworks are highly effective in explaining health inequities because they constantly ask: who benefits and who is harmed by the existing arrangements? They also integrate insights from fields like sociology, history, and ethics. A critical approach might note that even well-meaning health campaigns can fail if they don’t address root causes – for example, telling people to quit smoking has limited effect if they are stressed by unemployment and targeted by tobacco marketing in impoverished neighborhoods. By bringing in analyses of class, race, gender, colonialism, and neoliberalism, critical public health and anthropology ensure that explanations for disparities go beyond surface-level factors to include deeper structural drivers. These perspectives encourage activism and “speaking truth to power” within public health, aligning closely with the goal of equity.

13. Postcolonial Theory (Applied to Health)

Postcolonial theory examines how the legacy of colonialism – the historical and ongoing domination of one nation or people by another – continues to shape social conditions and knowledge systems, including in health. When applied to public health, postcolonial theory explains global and local health inequities as outcomes of colonial history and power imbalances between the West and the Global South, or between dominant and indigenous groups. For example, many low- and middle-income countries have health system challenges and disease burdens that are directly tied to colonial-era extraction of resources, destruction of institutions, and imposed economic structures. Postcolonial analysts point out that even after formal colonialism ended, neo-colonial arrangements (like unfair trade, debt, structural adjustment programs) have kept formerly colonized regions in a state of dependency and poverty, which manifest in poor health. They also highlight how Western-centric approaches can marginalize indigenous healing systems or community knowledge. In high-income countries, a postcolonial lens might be used to understand the health disadvantages of migrant communities or refugees as a continuation of global inequalities. This theory is effective for explaining, for instance, why sub-Saharan African countries faced such high HIV/AIDS burdens or struggle with health infrastructure – these issues cannot be divorced from a history of exploitation and the drawing of arbitrary national borders during colonial rule. Postcolonial theory in health also questions whose voices and values dominate global health discourse; it critiques the dominance of Western experts and calls for decolonizing global health practice. For health inequities, the implication is that we must understand historical context: health disparities often mirror colonial power dynamics (e.g. indigenous peoples vs. settler-descendant populations, or Global South vs. Global North). By acknowledging colonial and imperialistic causes behind health gaps – such as how colonial policies disrupted food systems leading to malnutrition, or how racism born of colonial attitudes leads to substandard care for minority groups – this framework provides a rich, contextual explanation of inequities and insists on remedies that include reparative justice and sovereignty for affected communities.

14. Elite Theory & Hegemony Theory (Power and Policy)

Both Elite theory and Gramscian Hegemony theory focus on how powerful groups shape society in ways that often maintain their advantage – offering insight into why health inequities persist politically and ideologically. Elite theory posits that a small group of elites (whether economic, political, or bureaucratic) dominate decision-making, even in democratic systems. In public health, this suggests that health policies and resource allocations may reflect the interests of the powerful rather than the needs of the most vulnerable. For example, elites may influence urban development to favor wealthy neighborhoods with good amenities while neglecting poor areas, or they may resist universal healthcare if it threatens their profits. This can explain why clear public health needs (like housing for the homeless, or pollution control in poor areas) often go unmet – those suffering have little political voice, while elites do not prioritize those issues. Hegemony theory, from Antonio Gramsci, adds an ideological dimension: it explains how the ruling class’s worldview becomes the “common sense” of society, causing even marginalized people to accept the status quo as natural or inevitable. In health terms, hegemony might manifest in widespread beliefs that blame individuals for their poor health (“it’s their lifestyle”) rather than questioning social conditions, thus deflecting challenges to the system. It also helps explain why there may be relatively little revolt against health inequities: if dominant narratives (often propagated by media or institutions controlled by elites) frame disparities as unfortunate but normal or as solvable by personal responsibility, structural change doesn’t garner momentum. Together, these theories effectively explain a frustrating reality: policies that could reduce health inequities often fail to materialize due to elite control and dominant ideologies. For instance, despite evidence that poverty drives ill health, redistributive policies may be blocked by influential lobbies or neoliberal ideology valuing “personal responsibility” over welfare. By identifying the role of power – both material and ideological – Elite and Hegemony theories tell us that health inequities are not merely technical problems but are sustained by political arrangements and narratives that benefit a few. Understanding this guides public health advocates to engage in power analysis and coalition-building to challenge elite interests and change prevailing narratives about health and social support.

15. Social Justice & Human Rights Approaches

These frameworks frame health inequities fundamentally as issues of justice and rights, asserting that achieving health equity is a matter of fairness, morality, and legal obligation. A social justice approach in public health holds that health is a public good and that society has an ethical duty to ensure equal opportunities for health for all its members. It emphasizes principles of equity (fair distribution of resources) and the concern for the most marginalized (often invoking the Rawlsian idea of improving the situation of the least well-off). When applied, this perspective interprets large health disparities as intolerable injustices resulting from policies and structures that distribute life chances unequally. It resonates with Dr. Martin Luther King Jr.’s famous quote that “of all the forms of inequality, injustice in health is the most shocking and inhumane.” A human rights-based approach similarly asserts that health is a fundamental human right – as declared in international documents like the Universal Declaration of Human Rights and WHO’s constitution. This means governments and the global community are duty-bound to ensure conditions for good health (clean water, housing, medical care, etc.) for everyone, without discrimination. When certain populations (say, people with disabilities, racial minorities, or the rural poor) have significantly worse health outcomes, a human rights lens sees this as a violation – someone’s rights to healthcare or to living conditions conducive to health are being unmet. These approaches are effective in explaining health inequities not by pinpointing a specific causal pathway, but by illuminating the ethical and structural dimensions: inequities persist because societal structures and policies are unjust, tolerating avoidable suffering among disadvantaged groups. They push analysis toward identifying whose rights are not being fulfilled and which laws or practices are enabling that denial. For instance, if minority populations face higher infant mortality, a rights-based approach would scrutinize failures in providing equitable healthcare access or addressing racism, framing these as rights violations. The strength of social justice and rights frameworks lies in galvanizing action – they provide a moral imperative and legal framework to address disparities. By asserting that health inequity is not just unfortunate but unlawful or unethical, they encourage robust interventions (like legislation, international aid, or litigation) to hold institutions accountable and to prioritize equity in all policies (the “Health in All Policies” approach rooted in equity). In sum, while these frameworks may not delve into biological mechanisms, they powerfully explain inequities as the result of societal choices and compel us to correct those injustices.

16. Capabilities Approach & Liberation Theology

Both the Capabilities Approach and Liberation Theology offer normative frameworks that help explain health inequities by focusing on human well-being, agency, and moral obligations to the oppressed. Amartya Sen and Martha Nussbaum’s Capabilities Approach argues that social arrangements should be evaluated by the extent to which people have the freedoms or “capabilities” to lead the kind of life they value – including the capability to be healthy. Health is seen as a critical capability that everyone should have the real opportunity to achieve. Inequities are thus understood as arising when social, economic, or political conditions deprive certain people of key capabilities. For example, if someone is living in a violence-ridden neighborhood with poor schools and no healthcare, they lack the substantive freedom to achieve good health, no matter how responsible they are individually. The capabilities framework is effective in explaining health inequities because it highlights opportunity deprivation – it directs attention to what people are actually able to do and be. Disparities then reflect that some groups do not have equal freedom to be healthy, due to factors like discrimination or poverty that society can and should remedy. It’s an equity-focused lens that goes beyond averages and asks whether each person has the means to thrive. Liberation Theology, arising from Latin American Christian thought (notably by Gustavo Gutiérrez), isn’t a conventional public health theory, but it has influenced community health work by positing a preferential option for the poor and viewing social injustice (including poor health among the oppressed) as a reflection of sin in societal structures. It essentially demands a moral and spiritual commitment to freeing people from oppression and meeting the needs of the most vulnerable. In health contexts, liberation theology inspires approaches that treat improving the health of the poor and marginalized as a sacred imperative. It helps explain inequities by casting them as the result of “structures of sin” or evil – in secular terms, deeply unjust systems – that must be transformed through collective action, compassion, and solidarity. For instance, a liberation theology-informed health project might emphasize empowering impoverished communities to voice their needs, and directly challenge policies that cause suffering (like lack of universal healthcare or environmental injustice), driven by a conviction that failing to do so is ethically wrong. While liberation theology is faith-based, its analysis of power and call for “liberation” of the oppressed resonates with secular social justice: both see stark health disparities as unacceptable and trace them to societal failings that we have a duty to change. In summary, the Capabilities Approach and Liberation Theology contribute to our understanding by reframing health inequities as unfreedoms or moral failings of society – people are ill not because of individual fault but because society hasn’t enabled their health or has actively oppressed them. This perspective strengthens the argument for holistic, humane policies that expand people’s real freedoms and uplift the poor as central to achieving health equity.

17. Community-Based Participatory Research (CBPR) & Community Organization Theory

These approaches are not traditional “theories” of causation but are methodologies rooted in the idea that community empowerment is essential to understanding and addressing health inequities. Community Organization Theory in public health focuses on mobilizing communities to identify problems and advocate for solutions, recognizing that those affected by issues (e.g. residents of a disadvantaged neighborhood) are experts in the realities and needs of their situation. It emphasizes grassroots leadership, capacity-building, and collective action – essentially shifting power to the community level. This is effective in the context of inequities because it counters the top-down approaches that often ignore local contexts and voices. Many health inequities persist because marginalized communities have historically been excluded from decision-making. Community organization seeks to change that by enabling communities to tackle issues like environmental hazards, lack of clinics, or unhealthy storefront marketing themselves, often resulting in more culturally appropriate and sustainable changes. Community-Based Participatory Research (CBPR) is a research orientation aligned with this: it involves community members as equal partners in the entire research process (from framing questions to collecting data to implementing interventions). CBPR arose from the recognition that traditional research often “helicoptered” in, studied communities, and left without benefit – sometimes even misinterpreting community realities. By contrast, CBPR posits that engaging the community’s knowledge and priorities will lead to more accurate findings and more effective interventions to reduce disparities. For instance, a CBPR project on diabetes in an Indigenous community would involve tribal members in designing the study around their cultural context and likely yield insights (and trust) that outsiders would have missed, leading to interventions that the community embraces. While these are approaches to addressing inequities, they also carry an explanatory insight: lack of community power is itself a cause of health inequity. If a community cannot influence the policies affecting their environment or services, inequities are likely to continue. CBPR and community organizing give communities tools to document and explain the problems they face (perhaps uncovering previously overlooked causes, like a local polluter or an absent grocery store) and to push for change. In sum, these frameworks demonstrate effectiveness by flipping the script – viewing communities not as passive victims of disparities but as agents capable of analyzing and changing the conditions that produce inequities. The success of many CBPR initiatives in reducing specific disparities (for example, improving lead contamination or increasing healthy food access in low-income areas) validates the idea that empowered communities can drive more equitable health outcomes.

18. Empowerment Theory & Praxis (Freirean Approach)

Empowerment theory in public health revolves around enabling individuals and communities to gain control over factors influencing their health, which is especially important for oppressed or marginalized groups. This theory suggests that when people increase their control, skills, and critical awareness, they are better able to improve their conditions – for example, by organizing for safer neighborhoods or advocating for better healthcare. In the context of health inequities, empowerment is both a means and an end: historically disempowered communities (racial minorities, low-income groups) often have the worst health outcomes, so building their power is a pathway to closing gaps. Brazilian educator Paulo Freire’s concept of praxis – reflection and action upon the world to transform it – heavily influences empowerment approaches. Freire’s work (like Pedagogy of the Oppressed) emphasized developing critical consciousness among the disenfranchised: through education and dialogue, people come to recognize structural injustices (such as inequity) and are motivated to act against them. In public health, this might translate into peer education programs that not only teach about disease prevention but also spur participants to challenge, say, unhealthy working conditions or discriminatory practices they face. Empowerment theory is effective in explaining health inequities to an extent: it highlights that powerlessness (lack of control, voicelessness) is a determinant of ill health. For instance, individuals with low health literacy or confidence may not navigate healthcare effectively, and communities that lack political clout may end up with toxic waste sites or no clinics in their area. By increasing self-efficacy, knowledge, and group organization, empowerment interventions tackle those intermediate causes of disparity. However, a critique (as noted by frameworks like PHL) is that empowerment efforts can sometimes focus too much on the individual level (“teach people to cope or be resilient”) without changing oppressive structures. The most robust empowerment models, influenced by Freire, avoid this pitfall by coupling personal skill-building with collective action for social change – ensuring that empowerment doesn’t become victim-blaming in disguise. When done right, empowerment and praxis can help explain positive deviances (why some disadvantaged groups manage better health – often they have strong community networks and agency) and guide effective interventions. Ultimately, these approaches underscore that people who are critically aware and organized can challenge inequitable systems – whether it’s protesting for clean water or demanding bilingual health services – thereby directly attacking the causes of health inequities. They blend explanation with solution, showing that part of why inequities exist is that oppressed groups have been intentionally kept disempowered, and the remedy lies in reversing that dynamic.

Mid Tier: Integrative and Partial Frameworks (Moderate Effectiveness)

19. Biopsychosocial Model

The Biopsychosocial model broadens the old biomedical model by asserting that biological, psychological, and social factors all play a role in health and disease. In clinical practice, this holistic perspective has been valuable – for example, recognizing that a patient’s heart disease might be influenced not only by their cholesterol (biology) but also by their stress or depression (psychological) and lack of social support or financial constraints (social). When it comes to explaining health inequities, the biopsychosocial model is moderately effective. On the one hand, it at least acknowledges social context, unlike the purely biomedical approach. It directs attention to how social determinants (like chronic stress from poverty or differences in health behaviors shaped by culture) contribute to illness. For instance, a biopsychosocial analysis of why a low-income community has high diabetes rates would include social components like food deserts or marketing of unhealthy foods, and psychological factors like depression linked to hardship, in addition to any genetic predispositions. However, the model often treats “social factors” somewhat generally and at the individual level (e.g. a person’s relationships or job stress), rather than analyzing larger structural forces. It may not explicitly account for power structures or historical inequalities that underlie those social factors. In other words, it is holistic for individual health, but not necessarily focused on systemic inequity. As a result, it can explain variability between individuals (why one person gets sicker than another) better than the patterned disparities between whole groups defined by social hierarchy. Still, if applied thoughtfully, the biopsychosocial model can incorporate insights from other theories – for example, noting that the “social” aspect includes experiencing racism or living in an under-resourced neighborhood (which connects to structural issues). In practice though, it sometimes becomes a catch-all without providing guidance on which social factors are most crucial. In summary, the biopsychosocial model represents progress over a biomedical lens by legitimizing psychosocial determinants, but it lacks a specific focus on inequity and power. It’s a good starting framework for comprehensiveness at the patient level, yet by itself it doesn’t fully illuminate why, say, entire marginalized communities systematically fare worse – for that, more critical or structural frameworks are needed alongside it.

20. Social Ecological Model (Ecological Systems Theory)

The Social Ecological Model (sometimes called Ecological Systems Theory in this context) explains health outcomes as the product of multiple levels of influence – ranging from individual factors to interpersonal relationships, institutions, community, and public policy. It essentially maps out that an individual’s health behavior or status is shaped by their immediate environment (family, peers), which is in turn shaped by broader community norms and resources, and ultimately by societal structures and policies. This model is widely used in health promotion to ensure that interventions address not just the person but also their context (e.g. creating supportive environments and policies). In terms of explaining health inequities, the socio-ecological model is helpful but somewhat generic. Its strength is that it prompts us to consider that disparities arise not just from individual choices (“eat healthier!”) but from factors at all levels – for instance, a high obesity rate in a low-income area might involve individual knowledge gaps, peer norms around food, school lunch policies, neighborhood safety for exercise, and federal food subsidy policies. By acknowledging the policy and community levels, this model aligns with the idea that structural factors matter, and it illustrates how inequities can be driven by higher-level forces (like unequal distribution of parks or hospitals, or discriminatory laws). However, the model itself doesn’t specify which factors at each level are most important or why those factors are unequal in the first place. It’s more of a framework for organizing influences. In practice, one could incorporate structural determinants into the outer layers (e.g. “societal level: systemic racism and poverty”) – indeed, some merged this with SDOH frameworks. When used in that way, the socio-ecological model can depict how racism at the societal level trickles down through community segregation, institutional bias (say, in healthcare or employment), strained interpersonal interactions, and individual stress, culminating in health disparity. On its own, though, the model doesn’t automatically prioritize power or economics; it’s possible to apply it superficially (for example, focusing on interpersonal and community tweaks without touching policy). Therefore, its effectiveness in explaining inequities really depends on how critically it’s applied. In summary, the socio-ecological model is a valuable schematic to ensure we look beyond the individual, and it can encompass the determinants of inequity across levels, but it doesn’t inherently drive a structural analysis unless equity-minded content is fed into it. It’s a versatile middle-ground framework – necessary but not sufficient for a full explanation of health disparities.

21. Health Impact Pyramid (Frieden’s Pyramid)

The Health Impact Pyramid, proposed by Thomas Frieden, is a framework that ranks public health interventions by their impact on population health. The pyramid has five tiers: at the base are interventions addressing socioeconomic factors (poverty, education, housing, etc.), followed by changing the context to make default decisions healthy (like clean water, fluoridation, food policy), then protective clinical interventions (like immunizations), then direct clinical care, and at the top health education and counseling. The key insight is that interventions at the base (upstream social determinants) have the greatest potential impact on health of the population, whereas those at the top (like one-on-one education) have the smallest impact. This model is very useful for explaining health inequities in terms of intervention effectiveness. It visually communicates that to significantly reduce disparities, we must act on the broad social level – for example, reducing poverty or improving living conditions will yield larger health gains (especially for the poor) than relying solely on individual behavior change. The pyramid indirectly explains why inequities exist: societies that don’t address the bottom layers (social determinants) will see big differences in health, because the top-layer measures (like telling people to exercise more) won’t overcome deeper structural gaps. Frieden notes that efforts “to address socioeconomic determinants of health have the greatest potential public health benefit” and require support of government and society. So the pyramid aligns with the idea that structural interventions (like policy changes) are most potent in closing health gaps. While not a theory of causation per se, it’s an explanatory tool that clarifies where disparities come from and how to reduce them. For instance, why is smoking much higher in low-income populations? The pyramid perspective would point to upstream factors (tobacco taxes, predatory marketing, stress from economic insecurity) and say modifying those (through policy) will do more to equalize smoking rates than an abundance of stop-smoking pamphlets (education) aimed at disadvantaged smokers. One limitation is that the pyramid is a broad conceptual model and might oversimplify complexity – in reality, multi-level approaches combined are ideal. But as a guide, it strongly reinforces the notion that social and policy changes yield greater equity, which is backed by countless examples (like how vaccination policies or adding folic acid to grains helped everyone but especially benefited those with less healthcare access). In summary, the Health Impact Pyramid effectively communicates the primacy of structural determinants in shaping health outcomes, thus explaining why focusing on those determinants is necessary to eliminate inequities.

22. Health Impact Assessment & PRECEDE-PROCEED Model

These are pragmatic tools rather than theories of causation, but they play an important role in addressing and thereby illuminating health inequities by ensuring policies and programs consider equity impacts. A Health Impact Assessment (HIA) is a process that evaluates the potential health effects of a proposed policy, plan, or project on a population – especially on vulnerable groups – and recommends strategies to manage those effects. By systematically forecasting how, say, a new housing development or a minimum wage law might affect different communities’ health, HIAs make the health equity implications explicit in decision-making. HIAs are grounded in the understanding that sectors outside health (transportation, urban planning, education, etc.) have huge impacts on health disparities. For example, an HIA might reveal that a proposed zoning change could either improve or worsen air quality in a nearby low-income neighborhood, thereby affecting asthma rates. In explaining inequities, HIAs highlight that many health determinants lie in policies that might not initially seem health-related – and they bring those to light to prevent widening gaps. The PRECEDE-PROCEED Model is a planning framework for health programs which stands for Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation (PRECEDE) and Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development (PROCEED). In simpler terms, it guides practitioners to start by assessing social, epidemiological, behavioral, and environmental factors (PRECEDE) and then implement and evaluate interventions (PROCEED). The strength of PRECEDE-PROCEED in equity is that it forces a thorough assessment of community needs and environment before jumping to interventions. It ensures planners ask: What are the quality of life issues in this community? What social or economic factors are enabling or reinforcing the health problems? For instance, using this model to plan an intervention for obesity in a marginalized community would surface issues like lack of grocery stores (environmental), norms around food or exercise (behavioral/cultural), and perhaps community concerns like safety or unemployment (social). By doing so, it implicitly explains that inequities (like higher obesity in one community) stem from these broader factors that must be addressed for the program to work. In the PROCEED phase, it also considers policy and organizational supports needed – aligning with multi-level action. While PRECEDE-PROCEED doesn’t inherently critique power, it is comprehensive and participatory, often involving the community in identifying problems and priorities, which helps ensure that structural barriers are recognized. Both HIA and PRECEDE-PROCEED contribute moderate explanatory power for inequities: they don’t provide a grand theory of why injustice exists, but they embed an understanding that context matters greatly for health. By institutionalizing the consideration of social and environmental factors (HIA in policy, PRECEDE in program design), they support the notion that to explain and fix health disparities, one must look upstream and involve the community. They move practice away from “one-size-fits-all” or purely individual-level interventions that often fail in disadvantaged settings, thus indirectly highlighting the causes of inequity (like poor living conditions or lack of empowerment) during the planning process.

23. Public Health 3.0

Public Health 3.0 refers to a modern paradigm for public health practice that calls for cross-sector collaboration, community engagement, and a focus on social determinants to advance health equity. This concept, promoted around 2016 by U.S. public health officials, recognized that the traditional public health (PH 1.0 being building basic infrastructure, PH 2.0 being evidence-based medicine and programs) needed to evolve to address 21st-century challenges. PH 3.0 envisions public health leaders as “chief health strategists” who work with non-health sectors like housing, transportation, education, and with community organizations, to create conditions for health. It explicitly underscores that achieving health equity requires policy and systems-level changes – for example, aligning city planning with health, or partnering with businesses to improve job conditions. In terms of explaining health inequities, Public Health 3.0 itself doesn’t introduce a novel causal theory, but it is built on the understanding that health inequities are rooted in societal factors and that siloed, purely medical approaches are insufficient. It is effective in that it drives home the point that health departments must tackle issues like poverty, discrimination, and lack of opportunity in order to make a dent in disparities. For instance, a PH 3.0 approach to chronic disease in a city would involve convening partners to improve parks, pass smoke-free housing ordinances, bring grocery stores to food deserts, and so on – implicitly explaining that the high chronic disease in certain neighborhoods stems from policy neglect and environmental deficits, not just individual choices. However, Public Health 3.0 has been critiqued by some as potentially “technocratic” – meaning it could become a top-down, management-heavy approach focused on data and systems alignment, without sufficiently incorporating community power or addressing deeper political determinants. If poorly implemented, one might get a lot of talk about multi-sector partnerships but shy away from more contentious structural issues (like redistribution of resources or challenging corporate interests). As an explanatory framework, then, PH 3.0 is only as strong as its emphasis on social determinants. At its best, it operationalizes the knowledge that inequities arise from factors like substandard housing or underfunded schools by forging solutions in those arenas. At its worst, it might gloss over power imbalances by focusing on “collaboration” without conflict. Overall, PH 3.0 represents an important shift of public health practice toward the domains that cause inequities, thus reinforcing those explanations, but it is more of a call to action than an analytical lens. It tells us where to intervene (upstream) and with whom (multiple sectors), based on the recognition that health is shaped by broad determinants – which is certainly aligned with explaining inequities in structural terms.

24. Cultural Competence Theory

Cultural competence in health refers to the ability of healthcare providers and systems to deliver services that meet the social, cultural, and linguistic needs of patients. Cultural Competence Theory posits that when health professionals are aware of and respect the diverse values, beliefs, and behaviors of patients – and can tailor delivery to patients’ cultural context – health outcomes improve, especially among racial/ethnic minorities and other marginalized groups. In explaining health inequities, cultural competence focuses on one piece of the puzzle: mismatch or bias in healthcare encounters. It recognizes that inequities in outcomes (like poorer quality care or patient dissatisfaction among minorities) often stem from communication barriers, lack of provider understanding of traditional beliefs, or even unconscious prejudice. By improving cultural competence (through training, diverse staffing, interpreter services, etc.), those inequities in care can be reduced. This is indeed a critical aspect – for example, Black patients often have better outcomes and higher trust when treated by Black physicians, suggesting cultural concordance matters. So cultural competence theory effectively explains some disparities as resulting from the healthcare system not being adequately responsive or respectful to all cultures. However, its scope is limited to the healthcare setting and individual interactions. It does not address broader structural causes of health inequities beyond healthcare access and quality. For instance, cultural competence won’t explain why certain communities have high uninsured rates or why they live in polluted areas – those require other frameworks (social determinants, structural racism, etc.). Additionally, if done superficially (like one-off cultural sensitivity workshops), it risks stereotyping or focusing on cultural “traits” while ignoring that patients’ behaviors often reflect their socioeconomic realities more than just ethnicity. Nevertheless, cultural competence has been key in highlighting how things like language barriers or mistrust (perhaps rooted in historical injustices like the Tuskegee syphilis study) contribute to inequity. It has driven changes such as development of patient navigator programs and community health workers who bridge cultural gaps. In summary, Cultural Competence Theory is moderately effective: it sheds light on healthcare-related contributors to disparities (like miscommunication, provider bias, lack of cross-cultural knowledge) and offers remedies to improve equity in care delivery. It is an important component for equitable healthcare systems, but by itself, it doesn’t tackle the upstream social and economic inequities that cause many health gaps before patients even reach the clinic.

25. Health Lifestyles Theory (Cockerham)

Health Lifestyles Theory, developed by medical sociologist William Cockerham, attempts to explain how patterns of health behaviors (like diet, exercise, smoking) are shaped by a person’s social context, particularly their class and social group affiliations. The theory builds on the idea of “life chances” (from Weber) and “habitus” (from Bourdieu) to say that people in similar social positions develop similar lifestyles, which include health-related habits. For example, middle-class professionals might as a group have lifestyles involving regular exercise and preventive healthcare, whereas working-class individuals under economic stress might have lifestyles with more smoking and convenience foods – not as an absolute rule, but statistically. These lifestyle choices are not purely individual preferences; they are influenced by factors like education, income, peer norms, work conditions, and the opportunities or constraints people face. Health Lifestyles Theory provides a descriptive link between social structure and individual behavior: it shows why unhealthy behaviors often cluster in lower socioeconomic groups (because of limited life chances, stress, different norms, marketing targeting, etc.). In explaining health inequities, this theory is insightful because it goes beyond blaming individuals and instead points to how class (and also gender, race, age) creates distinct environments and dispositions towards health behaviors. It highlights, for instance, that higher rates of obesity or smoking in disadvantaged populations are not simply due to lack of willpower but connected to structural factors – like physically demanding jobs leaving little energy for exercise, or cheap high-calorie foods being more accessible than fresh produce in poor areas. However, as noted, the theory is somewhat descriptive. It maps out the existence of these class-patterned lifestyles and their effect on health outcomes, but it doesn’t necessarily delve into power or policy. It might describe that the working class has a culture of heavy smoking, for instance, but to fully explain why that culture exists and persists, one might still need to consider targeted tobacco advertising or lack of smoking cessation resources – which calls for a deeper structural analysis. Health Lifestyles Theory also largely focuses on behaviors, which are only one part of health inequity (others being environmental exposures, healthcare, etc.). Thus, it’s a middle-tier theory: it effectively explains behavioral contributors to health disparities and shows how social stratification influences those behaviors, but it doesn’t encompass all causes of inequity. It is best used in conjunction with broader frameworks. It does, importantly, counter overly individualistic narratives by firmly linking lifestyle with life conditions.

26. Social Capital Theory

Social Capital Theory in public health explores how the features of social relationships and networks – such as trust, norms of reciprocity, and the extent of connectedness – can affect health. Social capital is often described as the resources available to individuals and communities through their social connections. High social capital communities are cohesive, with neighbors who support each other, shared norms (like looking out for children in the neighborhood), civic participation, and trust in institutions and among residents. Such communities, research finds, tend to have better health outcomes: for instance, lower crime, better mental health, and even longer life expectancy. Conversely, communities with low social capital (marked by isolation, distrust, and fragmented relationships) often see worse health. When explaining health inequities, social capital theory can be quite illuminating because social ties and support are protective factors that are unevenly distributed across society. Populations that face discrimination or high residential mobility (like immigrant groups or very poor urban areas) might have lower social capital due to external pressures or historical marginalization. This can partially explain disparities – for example, why some low-income neighborhoods have different health outcomes despite similar economic status: those with stronger community bonds may better cope with adversity, share resources, or collectively advocate for local services, compared to those that are socially fragmented. On an individual level, social capital might explain why, say, some elderly fare better (they have strong family and friend networks) than others who are isolated. Social capital theory also intersects with structural factors: segregation or economic inequality can erode social capital by fostering mistrust or reducing common spaces for interaction. So it indirectly highlights some upstream issues. However, a caution is that over-emphasizing social capital might inadvertently shift focus away from material conditions. While building community trust is good, it doesn’t replace the need for jobs, healthcare, or housing. Sometimes policymakers latched onto social capital as a silver bullet (“if the community just gelled together more, they’d be healthier”) which isn’t fair if structural deprivations remain. Also, social capital can have a “dark side” – tight-knit communities can also exclude outsiders or reinforce harmful norms. As a theory in health inequity, it’s moderately effective: it adds an important psychosocial and community-level explanatory layer (health isn’t just about one’s own income, but also about the social cohesion around you), but it shouldn’t be seen in isolation. It works best combined with analyses of economic and racial inequities. In practice, initiatives that foster community engagement, peer support groups, or neighborhood organizations often leverage social capital principles to improve health and can reduce some disparities (for example, community policing and neighborhood watch can reduce violence, or mothers’ groups can improve infant health in disadvantaged areas). Thus, social capital theory is a valuable piece of the puzzle, reminding us that social relationships are health resources that are unequally distributed and influenced by broader inequality.

27. Health Literacy Theory

Health Literacy refers to individuals’ ability to obtain, understand, and use health information to make appropriate health decisions. Low health literacy can lead to difficulties in navigating the healthcare system, misunderstanding medication instructions, or not grasping preventive measures, which in turn can result in poorer health outcomes. Health Literacy Theory emphasizes that it’s not just what health information is available, but whether people can comprehend and act on it, given their skills and the communication environment. In the context of health inequities, health literacy is an important factor because it often correlates with education, language, and cultural familiarity with the healthcare system – all of which vary by socioeconomic status and minority status. For instance, marginalized populations (those with less formal education, non-native speakers, the elderly, etc.) tend to have lower average health literacy, not due to any fault of their own but due to systemic factors like education inequality or medical jargon not accommodating lay understanding. As a result, those groups might less effectively manage chronic diseases, adhere to treatments, or utilize preventive services, contributing to disparities. Health Literacy Theory explains part of inequities by pointing out this mismatch between the complexity of health information and the capacities of different audiences. It has spurred interventions like simplifying medication labels, using visual aids, and teaching self-management skills, which have shown improvements especially for vulnerable groups. However, health literacy is a proximal explanation – it zeroes in on communication and knowledge gaps. It doesn’t tackle why those gaps exist (like why some people had limited schooling or why providers don’t communicate clearly across cultures). In that sense, it might treat a symptom of inequity (information asymmetry) more than the root cause. Still, improving health literacy is one of the more tractable ways to mitigate disparities in the short term: for example, ensuring that a diabetes education program is linguistically and culturally tailored can empower a community that might otherwise suffer worse outcomes due to misunderstandings. Moreover, health literacy theory has evolved to include the notion of “organizational health literacy” – i.e., making health systems easier to navigate – which places some onus on institutions to adapt, not just patients. In summary, Health Literacy Theory provides a moderate explanatory contribution: it highlights how differences in education and communication contribute to health gaps and emphasizes the need for accessible information as part of the solution. It reminds us that even with equal access to care, inequities could persist if information isn’t equitably understood. Yet, by itself, it’s insufficient to explain the full panorama of disparities, which also involve whether people have resources and rights to act on information even if they understand it.

28. Salutogenesis

Salutogenesis is a concept introduced by Aaron Antonovsky that shifts focus from factors that cause disease (pathogenesis) to factors that support human health and well-being. The core idea is to understand why people stay healthy, especially in the face of stressors. Central to salutogenesis is the notion of a “sense of coherence” – a person’s pervasive, enduring feeling of confidence that their environment is structured, predictable, and explicable, and that they have the resources to meet the demands it poses. People with a strong sense of coherence tend to cope better with stress and are more likely to maintain good health. In a broader sense, salutogenic approaches look for health-promoting factors – things like social support, meaningful employment, physical fitness, optimism, etc., that help individuals stay well. When it comes to health inequities, salutogenesis provides a somewhat different lens: rather than directly explaining why negative outcomes are higher in some groups, it asks why positive outcomes are higher in others, and how we can bolster those positive factors in all groups. For example, why do some individuals in a high-risk population nonetheless thrive? Perhaps they have strong community ties or a sense of purpose – salutogenesis would highlight those aspects. This is moderately useful in inequity discussions because it can help identify protective factors that disadvantaged groups may lack access to. For instance, affluent communities might have more of the salutogenic resources (like recreational facilities, job security, accessible healthcare, and a general sense of control over life), which could partly explain their better health. Meanwhile, marginalized groups often endure chronic stress with fewer buffers – salutogenesis would say their sense of coherence may be undermined by chaotic environments, discrimination, or lack of meaningful opportunities, leading to worse health. However, a critique is that focusing on salutogenesis can risk glossing over structural problems. Emphasizing resilience and coping (akin to salutogenic factors) in disadvantaged communities might inadvertently suggest that if they just had a better outlook or support, their health would improve – which is true to an extent, but doesn’t replace the need to remove the stressors and hazards they face. For example, teaching stress management (salutogenic) to people in violent, impoverished neighborhoods can help them individually, but it won’t eliminate the violence or poverty. Some have argued that overemphasizing resilience can even become a way to blame communities for not coping well enough, instead of holding systems accountable. That said, salutogenesis complements other theories by reminding us that health is not just avoiding risk, but actively building strengths. In equity terms, it urges expanding access to the resources that engender a sense of coherence – like education that fosters problem-solving skills, community organizations that build social support, or stable and fair socioeconomic conditions that make life more predictable. In summary, salutogenesis is moderately effective as an equity lens: it won’t pinpoint the origin of disparities as clearly as structural theories, but it adds value by identifying positive health assets and emphasizing holistic well-being which can guide interventions to help marginalized groups not just suffer less illness but actually thrive.

29. Resilience Theory

Resilience in a health context refers to the capacity to withstand or recover from adverse conditions. Resilience Theory examines why some individuals or communities achieve relatively good outcomes despite facing significant stressors or disadvantages. For example, a resilient youth in a rough neighborhood might avoid substance abuse and succeed in school despite the odds, perhaps due to protective factors like a supportive mentor or an internal locus of control. At a community level, resilience might involve strong social networks and cultural strengths that help buffer against, say, natural disasters or economic downturns. While resilience is undoubtedly a positive trait, as a framework for explaining health inequities it has a double-edged nature. On one hand, it highlights that outcomes are not deterministic – some groups beat the odds, which can offer clues to reducing disparities (maybe a particular coping strategy or community program is making a difference). It also encourages building resilience as part of public health strategies (for instance, fostering mental resilience in children through skills training or bolstering community cohesion). On the other hand, resilience discourse can inadvertently shift attention away from the root causes of adversity. If one focuses too much on “why aren’t these people more resilient?” it can imply that the onus is on individuals or communities to tough out hardships, rather than on society to remove the hardships. Critics note that resilience has sometimes been “foisted” on oppressed populations as an expectation – essentially saying, “Yes, you face racism/poverty, but you should bounce back”. This can disguise or distract from addressing structural inequities, effectively normalizing the adversity rather than preventing it. For example, during austerity, policymakers might celebrate communities’ resilience in coping with service cuts, instead of restoring services – painting resilience as a virtue to avoid fixing the underlying problem. In explaining inequities, an overemphasis on resilience might lead to blaming those who suffer worse outcomes for not being resilient enough, which is clearly problematic. That said, resilience theory does contribute by identifying protective factors – qualities or resources that allow some to fare better under the same hardship. This can complement other approaches: while we work to remove harmful exposures (like discrimination or poverty), we can also simultaneously strengthen protective factors (like ensuring supportive adult mentors for at-risk youth, or preserving cultural traditions that confer identity and support). Community resilience, for instance, has become an important concept in disaster preparedness and in addressing climate change impacts, which disproportionately hit marginalized communities; building local resilience is crucial as an adaptation strategy. In summary, Resilience Theory is moderately effective: it cannot be the primary explanation for health inequities (because it doesn’t question why some must endure so much adversity in the first place), but it adds nuance by highlighting variability in outcomes and encouraging supportive interventions. The key is to use it alongside structural change efforts, not instead of them.

30. Internalized Oppression Theory

Internalized Oppression refers to the phenomenon where members of a marginalized group internalize the negative stereotypes, beliefs, and attitudes that the dominant society perpetuates about them. In effect, the oppression takes hold inside their own minds. For example, an ethnic minority person might unconsciously come to believe that people of their ethnicity are inferior or prone to certain bad outcomes; or women might internalize sexist notions that they are less capable in certain fields. This can lead to diminished self-esteem, self-efficacy, and even replicating oppressive behaviors within the group. In terms of health, internalized oppression (such as internalized racism, sexism, or homophobia) can have deleterious effects. Psychologically, it contributes to chronic stress, depression, and anxiety – if you believe you are “less worthy” or expect discrimination as the norm, that’s a constant mental burden. Physiologically, chronic stress responses can increase the risk of hypertension, immune dysfunction, and other issues. Behaviorally, it might lead individuals to engage in unhealthy coping mechanisms (substance use, overeating) or to avoid seeking help (“people like me don’t get help” mindset). Internalized stigma around conditions like HIV or mental illness can also prevent people from accessing care. This theory is quite useful in explaining some of the more insidious, psychosocial pathways of health inequity. It shines light on how oppression doesn’t only harm through external barriers, but can also “get under the skin” via psychological pathways. For example, African Americans who have high internalized racism (believing negative stereotypes about their own group) have been found in some studies to have worse mental health and even indicators like higher blood pressure than those with low internalized racism – on top of the stress of dealing with external racism. Similarly, internalized homophobia has been linked to poorer mental health and risky behaviors in LGBTQ+ individuals. By recognizing internalized oppression, public health can tailor interventions: e.g. culturally grounded empowerment programs that actively counteract negative self-perceptions can improve health behaviors and outcomes. However, internalized oppression theory on its own addresses only one facet of inequity. It doesn’t directly explain structural differences in resources or exposure (why some neighborhoods lack clinics or have polluted water), but rather the added psychological toll of being in a subordinate position. It could risk psychologizing what are fundamentally social problems if misused – for instance, implying that marginalized people just need to “think better” of themselves, when in fact society needs to stop degrading them. Nevertheless, as part of a comprehensive understanding, it’s important: it explains why two individuals facing the same external oppression might have different health – one with severe internalized oppression might have worse outcomes than one with a strong sense of racial pride, for example. So it uncovers a layer of disparity in how oppression manifests within individuals. In summary, Internalized Oppression Theory contributes a moderate but crucial insight: oppression not only limits access to resources but can also erode one’s inner ability to cope and advocate, thus worsening health. Effective equity efforts should aim to undo not only the external inequities but also help people heal from and resist the internalized messages of inferiority or hopelessness that inequitable societies instill.

31. Urban Regime Theory

Urban Regime Theory comes from urban political science and seeks to explain how coalitions of local actors (political, economic, civic) govern cities and shape policy outcomes. It posits that in many cities, an informal regime – often a partnership between city government and business elites (developers, corporations) – drives the urban agenda, deciding on development priorities, resource allocation, and so forth. These regimes are concerned with maintaining economic growth and their own power, which can lead to decisions that favor downtown business interests or affluent neighborhoods at the expense of marginalized communities. When applied to public health inequities, Urban Regime Theory can explain why certain health-promoting policies (like affordable housing, pollution controls, or investments in poor neighborhoods) may struggle to gain traction if they conflict with the interests of the ruling regime. For instance, if an urban regime is tightly allied with real estate developers, the city might prioritize upscale developments over building clinics or parks in underserved areas, or might neglect infrastructure (like water systems, public transit) in low-income areas, contributing to disparities. It also sheds light on why some cities adopt progressive health equity initiatives while others do not – it often depends on whether the governing coalition includes advocates for the poor or is solely growth-oriented. For example, a city regime that includes strong community organizations might implement policies to reduce health inequities (like expanding Medicaid access locally or investing in minority-owned businesses), whereas a regime dominated by business may resist such redistributive measures. Urban Regime Theory is moderately effective in explaining inequities because it points to power and governance structures at the city level as determinants of health outcomes. Many health determinants (housing, education, policing, sanitation) are influenced by local policy, so who has influence at City Hall matters. It essentially argues that health equity or inequity in a city is politically produced by the governing regime’s priorities. One limitation is that it’s very context-specific – regimes vary widely, and the theory is more about the process of decision-making than the content of specific health issues. Also, it’s not a comprehensive health theory; it doesn’t inherently address clinical care or individual behavior. But as a piece of the puzzle, it emphasizes the need to consider local political context in understanding disparities. For example, why is childhood lead poisoning still an issue in one city and not in another? Urban regime theory might reveal that in the former, landlords and their political allies have blocked lead abatement enforcement. Or why do food deserts persist? Perhaps the regime doesn’t prioritize grocery access in poor areas because those communities lack political clout. Recognizing these dynamics is key for those trying to change policies: it’s not just about evidence of a health need, but about building coalitions to alter the urban regime or its decisions. In summary, Urban Regime Theory provides a valuable explanation for health inequities by highlighting the role of urban power structures and coalitions in distributing health resources and risks, although it should be used alongside other perspectives for a full picture.

32. Political Realism (International Relations, adapted to Health)

Political Realism in international relations is the theory that nations primarily act in their own self-interest, prioritizing power and security over ideological or ethical concerns. Adapted to global health, a realist perspective suggests that global health inequities persist in part because powerful nations (and actors) pursue policies that serve their interests, often at the expense of poorer populations. For example, during global outbreaks or in distributing resources, countries may hoard supplies or prioritize their own populations (as seen in “vaccine nationalism” during the COVID-19 pandemic). Realism would predict that even in cooperative forums, each state will covertly or overtly try to ensure it benefits more, which can leave weaker states behind. This theory explains phenomena like unequal access to medicines: wealthy countries protect pharmaceutical patents and negotiate trade deals that favor their companies, making lifesaving drugs unaffordable in poorer countries – a very realist, interest-driven outcome. In terms of why some countries have drastically different health outcomes, realism points to global power imbalances: historically, powerful countries extracted resources and left weaker regions impoverished (colonial legacy), and today they might shape international institutions or funding priorities in ways that align with their interests rather than global equity. For instance, global aid might be directed less to where the health need is greatest and more to where donor countries have strategic interests. Political Realism can also be applied within countries in a sense – viewing different factions or interest groups as acting self-interestedly in health policy debates (though that overlaps more with elite theory). As an explanatory framework for inequities, realism brings a cynical but often accurate lens: it suggests that health inequities are not merely accidental or due to lack of knowledge, but are allowed or even caused by deliberate choices of those protecting their own advantage. It can explain why obvious global health problems (like lack of clean water or basic vaccines in poorer nations) remain unsolved despite technical ability – there isn’t a sufficient alignment of interests for powerful actors to resolve it. However, realism on its own is somewhat blunt. It might overemphasize conflict and understate instances of genuine altruism or cooperation in global health (like eradication of smallpox, or countries working together on polio elimination). It also doesn’t inherently provide solutions – it might even imply that unless something becomes in the interest of the powerful, inequities will continue, which can be a pessimistic view. But being aware of realist dynamics is crucial for pragmatic action: for example, understanding that appeals to humanitarian values may not sway a country unless you also address their national interest can guide more effective advocacy (like framing global health aid as also protecting the donor country’s security by preventing disease spread). In summary, the adapted Political Realism perspective is moderately effective: it explains inequities as outcomes of power politics on the global stage, shining light on why well-intentioned initiatives might fail when they collide with state or corporate interests. It reminds us that equity in health often requires tackling or aligning with the interests of the powerful, not just presenting moral arguments. It’s a valuable angle, but should be balanced with other views since not all global health progress can be reduced to pure power plays.

33. Information-Motivation-Behavioral Skills Model (IMB)

The IMB model, initially developed in the context of HIV prevention, holds that for someone to adopt a healthy behavior, they need: information (knowledge about the behavior and its importance), motivation (personal and social motivation to perform it), and behavioral skills (the practical ability and self-efficacy to do it). If any of these components is lacking, behavior change is less likely. For example, to adhere to HIV medication, a patient needs information (how and why to take it), motivation (wanting to stay healthy and perhaps social support to do so), and skills (like organizing a routine, dealing with side effects). The IMB model is very useful for designing targeted health interventions because it pinpoints exactly where the barrier might be (is it a knowledge gap? Stigma reducing motivation? Lack of skill in, say, negotiating condom use?). However, as an explanatory framework for health inequities, IMB is limited to the micro level. It’s focused on individual behavior change and the immediate factors influencing it, rather than the structural environment. It can explain differences in outcomes to some extent: for instance, why might one community have lower uptake of colon cancer screening? According to IMB, perhaps they have less information (no one has conducted effective outreach in their language), or lower motivation (maybe due to fatalism or low trust in healthcare), or skill barriers (maybe they don’t know how to navigate appointment systems or lack transportation – which could be considered a skill/environment issue). Indeed, these factors often do differ by social group, usually because of structural reasons (like less access to information due to language barriers or lower quality education, or lower motivation due to negative experiences with the system). IMB allows us to articulate those proximate causes and design interventions – e.g., a program to boost motivation by using peer educators in a community that distrusts outside authorities. But IMB doesn’t inherently address why those differences in information or motivation exist – that might be due to inequities in education, discrimination eroding motivation, etc., which IMB doesn’t explicitly cover. It also doesn’t cover conditions where the main problem isn’t knowledge or motivation at all but structural lack of resources. For example, someone might be fully informed and motivated to exercise but still unable to because their neighborhood lacks sidewalks or they work two jobs (a structural barrier beyond “behavioral skill”). The IMB model would classify that as a skill barrier maybe (no time management ability), but that would be a stretch – it’s not designed for structural critique. In summary, the IMB model is an individual-level behavior change framework that is moderately useful in explaining disparities insofar as many inequities do involve differences in health behaviors (like varying rates of smoking, safe sex, medication adherence among groups) and those differences can be partially traced to information, motivation, and skill gaps. Using IMB can lead to effective educational and psychosocial interventions targeted to disadvantaged groups, which can reduce disparities (e.g., improving diabetes self-management in a community by addressing health literacy and motivation). Yet, IMB alone cannot address deeper causes of inequity – it doesn’t ask who structurally has access to information or who benefits from keeping people unmotivated. It’s best applied in combination with strategies that modify the environment, ensuring that information and motivation can actually be acted upon.

34. Diffusion of Innovations Theory

Diffusion of Innovations (Everett Rogers’ theory) explains how new ideas, practices, or technologies spread through societies over time. It categorizes adopters into innovators, early adopters, early majority, late majority, and laggards, and discusses factors that influence diffusion, such as the innovation’s relative advantage, compatibility with values, complexity, trialability, and observability. In public health, this theory is often used to understand how health interventions (like a new vaccine, a health app, or a sanitation practice) get taken up by a population. While diffusion theory is not specifically about inequity, it has important implications for it. Historically, innovations – including health innovations – tend to be adopted earlier by more advantaged groups, and later (if at all) by disadvantaged groups. This pattern can temporarily or even persistently widen health disparities. For example, when a breakthrough medication is introduced, wealthier or better-educated patients might hear about it and access it first, while poorer patients lag behind, leading to a bigger gap in outcomes. The theory describes mechanisms like information flow (the advantaged might be better connected to information channels), perceived need (sometimes those in dire need adopt quickly, but if an innovation requires resources, need alone isn’t enough), and social influence (people often adopt based on peers – if one’s peers aren’t adopting because of cost or skepticism, diffusion stalls). Diffusion of Innovations can thus explain why some public health measures take much longer to reach certain communities – often those who are rural, low-income, or socially marginalized – thereby contributing to inequity. A classic example: the diffusion of the back-to-sleep campaign (to prevent SIDS) or breastfeeding practices differed by socioeconomic and racial groups, initially increasing gaps in infant health outcomes between groups that adopted earlier vs. later. The theory also highlights how cultural compatibility and targeted communication channels matter; if an innovation is packaged in a way that doesn’t resonate with a particular group’s values or if information isn’t reaching them via trusted messengers, they will be late adopters. Knowing this, public health practitioners use diffusion insights to tailor early dissemination efforts to include marginalized groups (e.g., engaging community leaders as “early adopters” to influence others). However, diffusion theory itself doesn’t address power dynamics directly – it treats the process somewhat neutrally. It doesn’t ask, for example, why some groups lack access to the innovation (cost, gatekeeping by companies, etc.) or how inequality in resources affects the ability to adopt. We must overlay that knowledge: often the reason diffusion is slow in a population is because of structural barriers or mistrust rooted in historical marginalization. So, diffusion theory is moderately effective: it provides a framework for understanding temporal aspects of inequity (who benefits first vs. later from a new health measure) and suggests strategies to speed adoption in lagging groups, but it doesn’t inherently critique why those groups were “laggards” (which might be due to inequity itself). In summary, diffusion of innovations is a valuable tool for public health to predict and attempt to prevent inequitable uptake of interventions by intentionally inclusive diffusion strategies, thus ensuring innovations don’t just improve health for the well-off, but for everyone.

Lower Tier: Individualistic and Narrow Theories (Least Effective)

35. Biomedical Model

The traditional biomedical model views health and disease primarily through a biological lens, focusing on physiology, pathology, and biochemistry. It attributes illness to specific, identifiable biological causes (viruses, bacteria, genetic mutations, etc.) and tends to exclude social, psychological, or behavioral dimensions as outside its scope. While this model has been extraordinarily successful for many medical advances, it is highly limited in explaining health inequities. Under a strict biomedical view, if two groups have different health outcomes, one would first look for biological differences – perhaps genes or innate differences in disease susceptibility. Historically, this led to misguided notions of racial biology or seeing poor health among the disadvantaged as a result of hereditary inferiority or individual defects. However, decades of research have shown that large health disparities (e.g., differences in life expectancy by socioeconomic status or race) are overwhelmingly driven by social determinants, not genetic differences. The biomedical model, by ignoring context, fails to account for why certain populations consistently experience more illness. For example, it can identify that lead poisoning causes neurological damage (biological mechanism), but not why children in poor neighborhoods are more likely to be exposed to lead. Or it can treat a patient’s hypertension with drugs, but not explain why hypertension prevalence is higher in Black Americans (the answers lie in factors like chronic stress from racism, diet shaped by economic access, etc., which are invisible to a pure biomedical approach). In fact, reliance on the biomedical model alone has at times contributed to inequities – for instance, by focusing on expensive clinical treatments that only those with access can get, rather than preventive measures. It also can blame individuals for diseases (“it’s just their genes” or “their risky behavior”) rather than examining systemic causes. As a result, leading public health voices have called for moving beyond the biomedical model to incorporate social determinants. In terms of explanatory power, the biomedical model is at the bottom tier for inequities: it might accurately explain the immediate cause of one person’s disease (e.g., a virus caused their infection), but it cannot explain patterns across populations (e.g., why viruses infect some communities more than others) because it deliberately leaves out the social environment. As Margaret Chan’s quote highlighted, healthcare and lifestyle are important, “but… it is factors in the social environment” that determine health patterns – something the biomedical model doesn’t address. Of course, biology is not irrelevant – genetics and physiology mediate how social exposures cause disease – but by itself, the biomedical model offers a fragmented view. If one tried to tackle health disparities with a purely biomedical approach, one might sequence genomes or develop new drugs, which could yield helpful knowledge, but one would miss the big picture that inequities are largely man-made by social conditions. Thus, while indispensable for clinical medicine, the biomedical model is woefully insufficient for explaining and addressing health inequities, and ranks among the worst frameworks in this regard.

36. Health Belief Model (HBM)

The Health Belief Model is a psychological model that explains health behaviors by an individual’s beliefs about health problems, perceived benefits of action, barriers to action, and self-efficacy. It suggests that a person will take a health-related action (like getting vaccinated or using a condom) if they 1) feel susceptible to a condition, 2) believe the condition could have serious consequences, 3) believe taking the action would reduce their susceptibility or severity (perceived benefit), 4) don’t see overwhelming obstacles to taking that action (perceived barriers), and 5) have confidence in their ability to successfully perform the action (self-efficacy, added later). Cues to action (like reminders or symptoms) can trigger the behavior as well. The HBM has been widely used for designing health education and interventions – and it has empirical support for certain behaviors – but it has notable limitations, especially for addressing health inequities. The model is very individual-centric and cognitive: it assumes people make rational assessments of risk and benefit, and that modifying those perceptions will change behavior. However, it does not account for many external factors that influence behavior. As the literature notes, HBM doesn’t incorporate habitual behaviors well or behaviors performed for non-health reasons (e.g., exercising for enjoyment vs. health). Critically, it largely ignores environmental and social constraints that can prevent behavior even if someone is motivated. For instance, a person might very much want to eat healthy (perceived benefit high, perceived severity of disease high, etc.), but if they live in a “food desert” or can’t afford fresh produce, HBM doesn’t explicitly capture that barrier (unless you stretch “perceived barrier” to include environmental barriers, but originally it was more about things like cost or inconvenience as perceived by the individual). Indeed, the HBM acknowledges “modifying factors” like demographics and knowledge in a limited way, but does not delve into how those factors structurally shape options. When explaining health inequities, HBM falls short because disparities are often not due to differences in perceptions alone. For example, low-income individuals may rate their susceptibility to illness as high and desire to be healthy just as much as anyone (some studies show perceived threat can be high in disadvantaged groups), but still have worse outcomes due to factors outside the HBM’s scope: inadequate access to care, environmental exposures, chronic stress, etc. HBM might attribute low cancer screening rates in an underserved community to low perceived benefit or high perceived barriers in the psychological sense (like fear of finding cancer, or distrust), which can be part of the story – and indeed distrust or fatalism are barriers amenable to intervention. But the model would not direct us to solutions like “increase insurance coverage” or “provide paid time off for medical visits” or “improve the quality of local clinics,” because those are not individual beliefs. In short, HBM can offer partial insight (some disparities do involve differences in health knowledge or cultural beliefs about illness, which HBM would highlight), but it ignores the structural environment so much that it’s one of the less effective frameworks for fully explaining inequity. Empirically, a review noted HBM constructs are broadly defined and it doesn’t specify how they interact, making it tricky even to compare across studies. Overall, HBM is a useful tool in designing certain health messages, but for inequities it’s near the bottom: it risks “blaming the victim” by focusing only on what the individual believes and does, while sidestepping how society limits their choices or knowledge. As public health has shifted towards social determinants, models like HBM have been critiqued for their narrowness. Therefore, HBM ranks as one of the least effective standalone theories for understanding health disparities.

37. Theory of Planned Behavior / Reasoned Action

The Theory of Planned Behavior (TPB) and its predecessor, the Theory of Reasoned Action (TRA), are psychological models that aim to predict intentional behavior. TRA posits that a person’s behavior is driven by their intention to perform it, which in turn is influenced by their attitude toward the behavior (beliefs about outcomes and evaluations of those outcomes) and subjective norms (beliefs about whether important others think they should do it, and motivation to comply). TPB added a third factor: perceived behavioral control (similar to self-efficacy, one’s confidence in their ability to execute the behavior), acknowledging that if people feel they lack control, they might not form a strong intention even if they have positive attitudes and supportive norms. TPB/TRA have been applied to numerous health behaviors (from safe sex to diet to smoking cessation) with some success in explaining variance in intention and behavior. However, like HBM, TPB/TRA focus on individual decision-making and assume a more or less rational thought process leading to action. They are largely apolitical and acontextual. These models don’t inherently consider structural barriers or enabling environments – instead, everything is filtered through individual perceptions. If a community has low physical activity, TPB would have us examine attitudes (do they value exercise?), norms (do their friends exercise?), and perceived control (do they think they can fit exercise in?) which are all relevant. But it might miss that there are no safe parks or sidewalks – unless those external factors are captured indirectly by perceived control (“I don’t think I can because it’s unsafe outside”). So, external realities only enter if individuals perceive them as barriers; the model doesn’t mandate examining objective barriers or unequal distribution of those barriers across populations. In explaining inequities, TPB/TRA are inadequate because they don’t address why different groups might have different attitudes, norms, or control. Often, those are shaped by structural conditions and culture. For instance, subjective norms around drinking or diet differ by social group, but those norms themselves arise from historical, economic, and marketing influences. Similarly, perceived control can be low in disadvantaged groups because they genuinely face more obstacles – but TPB treats it as a subjective factor. Moreover, TPB/TRA assume that changing attitudes and intentions will lead to behavior change if control is also there – but evidence shows intention-behavior gaps, especially in contexts of poverty or stress (you may intend to eat healthy but financial or emotional stress derail you). The models also generally consider one behavior at a time; life for disadvantaged individuals often involves juggling many pressing issues, which can override specific intentions (this multi-problem reality is outside TPB’s scope). Another critique: they ignore power and politics entirely. They are apolitical by design – focusing on internal cognitive predictors. So they would not help explain phenomena like why tobacco use fell in higher SES groups before lower SES groups (except via saying norms changed earlier among high SES). The real reasons included differential tobacco marketing and policy adoption, which TPB wouldn’t capture. Given these limitations, TPB/TRA rank low for explaining inequities. They have been called out for being ahistorical and individualistic, thus “apolitical” as the prompt noted. While useful in designing behavior change communications, they must be embedded in a larger strategy that addresses contextual factors. By themselves, they might inadvertently suggest that, say, the reason a low-income community has worse health is that their attitudes and intentions are “wrong,” ignoring that those attitudes might be shaped by very rational responses to living in hardship. Therefore, TPB and TRA are among the least effective theories for capturing the why of health disparities, since disparities are largely driven by social and economic forces outside the individual headspace.

38. Stages of Change Model (Transtheoretical Model)

The Stages of Change or Transtheoretical Model (TTM) conceptualizes behavior change as a process through a series of stages: typically precontemplation (not considering change), contemplation (aware of problem, considering change), preparation (getting ready to change), action (actively making change), and maintenance (sustaining the change). There’s also recognition of potential relapse, where one might slip back to an earlier stage. This model is useful for tailoring interventions to a person’s readiness – for instance, using different strategies for someone who isn’t even thinking about quitting smoking versus someone who is actively trying to quit. For individual change, it’s a helpful framework (e.g., motivational interviewing is often guided by identifying a client’s stage). However, regarding health inequities, the Stages of Change model has minimal explanatory power. It deals with how individuals change behavior, not why certain populations have more difficulty adopting healthy behaviors or face higher risks. It implicitly treats behavior change as an individual journey. If one wanted to apply it to disparities, one might look at whether disadvantaged groups disproportionately lie in earlier stages for key behaviors (for example, are low-income individuals more likely to be in precontemplation about cancer screening?). If so, one could tailor programs to move them along stages. But why are they in precontemplation? The model doesn’t tell us. It could be due to lack of awareness (less access to health information), or fatalism (due to cultural experience or historical mistrust), or immediate survival priorities (you can’t contemplate exercise when you’re worried about food) – all structural or social reasons outside TTM’s scope. Also, a focus on stages might inadvertently blame the individual for “not being ready,” whereas in reality external conditions might prevent them from taking action even if they want to. For instance, someone might be in the maintenance stage for healthy eating – they’ve been eating well for months – but then a financial crisis hits and they relapse not due to internal lack of commitment, but due to external shock. TTM wouldn’t capture that context, other than labeling it a relapse. It also doesn’t address how to change external conditions to support maintenance (that would come from other theories). So, while Stages of Change is a handy clinical or counseling tool, it does not explain population-level patterns of behavior or outcomes. If we see differences in behavior change success between groups (e.g., one group has more smokers quitting than another), TTM would have us check differences in their stage distribution – maybe one group has more in precontemplation. That still begs the question of why. And often, those reasons circle back to inequities in knowledge access, stress levels, resources, or cultural tailoring of interventions, none of which TTM directly addresses. Furthermore, TTM typically focuses on volitional behaviors, which may not address issues like environmental exposures or access to services that also drive disparities. Thus, the Transtheoretical Model is one of the less useful frameworks for explaining health inequities, since it centers on personal change process absent context. It doesn’t inherently incorporate social support or community factors either (though one could embed it in a larger program). In ranking, it sits near the bottom – not because it’s wrong, but because it’s too behaviorist and stage-focused to account for the structural realities that differentiate group health outcomes.

39. Precaution Adoption Process Model

The Precaution Adoption Process Model (PAPM) is another stage-based model, specifically describing how people come to a decision to take action (or not) on a health precaution (like installing a smoke detector, getting a vaccine, etc.). The stages typically go: unaware of the issue, unengaged by the issue, deciding about acting (which can lead to either deciding not to act or deciding to act), acting, and maintenance of action. It’s similar to TTM but more tailored to one-time or periodic precautionary actions and includes the stage of deciding not to act. PAPM is good for identifying where people drop off in terms of, say, adopting radon testing in homes or evacuating during a hurricane. Like other stage models, PAPM is individual-oriented and focuses on cognitive steps. For health inequities, PAPM by itself offers little. It can break down which stage different demographic groups are stuck at for a given precaution – perhaps a disadvantaged group is mostly in “unaware” or “unengaged” stages about a certain screening, whereas a more advantaged group mostly is in “deciding” or “action” stages. That can guide targeted education or motivation efforts to move the needle. However, the model doesn’t incorporate why one group might be less engaged or more hesitant – those reasons could be tied to trust, education, accessibility, or cultural beliefs, all shaped by broader social forces. PAPM doesn’t factor in structural barriers in taking action either; it focuses on the mental journey to a decision. Once the person has decided to act, PAPM assumes action occurs, but in reality, for some groups, deciding to get a colonoscopy doesn’t ensure they can afford it or access it. As such, PAPM might overestimate the ease of action for marginalized people. Also, PAPM’s stage of “decided not to act” might be common in some communities not because they truly evaluated and refused, but because of misinformation or mistrust – which again ties back to deeper issues like institutional racism or historical neglect (things PAPM doesn’t explicitly consider). In sum, Precaution Adoption Process Model is narrow in scope: it’s about how individuals process information and decisions regarding preventive actions. It doesn’t address differences in information availability (someone can’t become “aware” if no one informs them, often a disparity issue) or differences in opportunity to act. It’s somewhat better than nothing for thinking about engagement levels, but overall ranks low for explaining inequities. It would need to be embedded in a socio-cultural analysis to be really useful: e.g., acknowledging that unawareness in a community might be due to lack of outreach by a health system that historically ignores that community. By itself, PAPM is among the less effective frameworks in this list for understanding why health gaps exist.

40. Protection Motivation Theory

Protection Motivation Theory (PMT) is a psychological theory that explains how people respond to threats, often used in the context of fear appeals in health messaging. It posits that when people are faced with a threatening health message, they appraise the threat (perceived severity and vulnerability) and appraise their coping ability (response efficacy – will the recommended action avert the threat; and self-efficacy – can I perform the action). Based on these, they generate protection motivation which leads to behavior change (or not). Essentially, if a person believes “the threat is serious, I am at risk, the recommended action works, and I can do it,” they’ll be motivated to protect themselves (e.g., quit smoking upon hearing it causes deadly lung cancer), whereas if any of those beliefs falter (e.g., “I can’t quit anyway” or “the risk is exaggerated”), they won’t act. PMT can explain differing responses to health campaigns or warnings among individuals. For inequities, however, its perspective is limited to the cognitive appraisal of threats and coping. It might help explain, for example, why anti-smoking campaigns historically had varying impacts: some populations might have low self-efficacy or different risk perceptions due to educational differences – so a campaign that scared middle-class smokers into quitting might not work for lower-income smokers who feel less able to quit or more resigned to risk. But beyond such scenarios, PMT doesn’t cover the landscape of inequity causes. It’s about motivation in the face of fear – it doesn’t consider chronic stressors or environmental constraints. In fact, heavy emphasis on fear appeals in disadvantaged communities can backfire if people feel powerless; they may engage in fatalism or denial (a maladaptive response not explicitly detailed in PMT, though extensions of the theory consider it). For example, telling a low-income person about all the cancer risks they face might not spur action if they also think “but I can’t afford the solutions” – they might just become more fearful or ignore the message to cope. This theory doesn’t engage with how structural factors influence those appraisals. Perceived efficacy in a population can be low because, structurally, they haven’t been given resources or success experiences (for instance, many failed attempts to get healthcare might reduce self-efficacy to deal with health threats). PMT doesn’t fix that except to say increase self-efficacy via interventions, which often means better communication or small skill-building, not larger empowerment or resource provision. In summary, Protection Motivation Theory is fine for designing specific health communications and understanding individual decision-making under threat, but it barely scratches the surface of inequity drivers. At best, it might explain differential behavior change success after an intervention (like why only some people respond to a scare-tactic advertisement), attributing it to differences in threat/coping appraisal. But those differences are themselves symptoms of deeper inequities (education, trust, agency). PMT isn’t built to address those, hence as an inequity explanation tool it ranks very low. It’s quite narrow and arguably one of the least effective frameworks for big-picture disparities, since fear and coping appraisals are just one small piece of the health behavior puzzle, and one that is highly individual.

41. Social Cognitive Theory & Self-Efficacy

Social Cognitive Theory (SCT), developed by Albert Bandura, emphasizes that behavior is influenced by an ongoing interaction between personal factors, behavioral patterns, and environmental factors (reciprocal determinism). Key constructs include observational learning (people can learn by watching others), outcome expectancies, and crucially self-efficacy, which is the confidence in one’s ability to perform a behavior. SCT acknowledges that the environment (including social milieu) can promote or hinder behaviors, and that people are not just passive – they exert agency in their environment. Self-efficacy has been singled out as particularly important; without belief in one’s ability, even well-intentioned individuals may not persist in behavior change. When considering health inequities, SCT is more comprehensive than HBM or TPB in that it explicitly factors in environment and has a concept of how structural factors could be manipulated (by changing environment to support the behavior). For instance, SCT would suggest that to improve physical activity in a community, one should not only educate individuals (personal factor) but also provide role models and social support (social environment) and facilities (physical environment), and build people’s confidence through gradual successes. If a disadvantaged community lacks these supports, SCT would predict lower adoption of the desired behavior. So SCT can explain disparities to some extent: many marginalized groups are in environments less conducive to healthy behaviors (fewer models of success, more barriers, less reinforcement), which results in lower self-efficacy and worse health behaviors. For example, youth in a high-crime, low-resource neighborhood might have fewer opportunities to observe peers succeeding academically or being physically active, and more stressors, leading to lower expectations and self-efficacy around health, perpetuating risk behaviors. By addressing self-efficacy and environment, interventions can yield improvement (e.g., diabetes management programs that build self-efficacy see better results in historically underserved patients). However, SCT still is primarily a behavior change theory and doesn’t inherently tackle macro-level power or policy. It would say improve environment, but in practice, creating those supportive environments often runs into larger political issues (like who funds a park or a clinic). It’s not a theory of political change or resource distribution. Moreover, SCT might not fully address how chronic poverty or discrimination – factors beyond day-to-day observational learning – erode health, except through their effect on behavior or maybe emotional coping. Many health inequities (like higher infant mortality in Black women) are not due to “behaviors” but due to differential treatment and stress, which SCT doesn’t explicitly model. Unless one extends “environment” to include institutional discrimination (which one could, but Bandura’s typical examples are more like family, peer influence, media, etc.), it might miss those structural determinants. Self-efficacy theory specifically has been very useful in interventions (it’s easier to change someone’s self-efficacy than their entire environment sometimes), and indeed low self-efficacy is more common among those who have historically faced failure or lack of opportunity – which often correlates with poverty and marginalization. That said, boosting self-efficacy is a partial fix if the structural barriers remain high; you can make someone feel more confident, but if the system still blocks them, outcomes may not improve. So, we rank Social Cognitive Theory and its self-efficacy component as low on explaining inequities, albeit higher than purely individualistic models. It acknowledges environment and has a dynamic view of interaction, but it still centers on personal change and proximal environment (like family, immediate community) rather than distal structural forces like policies or economics. It doesn’t inherently consider historical or societal power disparities. For explaining something like the persistence of racial health disparities, SCT provides some insight (differences in learned behaviors and support) but falls far short of a full explanation (ignoring structural racism’s direct impacts). Thus, it is among the less effective for macro-level inequity explanations, even though it’s very influential for designing interventions at the individual and small group level.

42. Behavioral Economics & Nudge Theory

Behavioral Economics brings psychological insights into economic decision-making, recognizing that people often do not act as purely rational actors and are influenced by biases, heuristics, and framing. In public health, this field has popularized “nudge theory”, where subtle changes in choice architecture (the way choices are presented) can encourage healthier behaviors without restricting freedom – for instance, making the healthy food option the default, or using incentives and reminders. Examples include automatically enrolling employees in wellness programs (with opt-out), or placing eye-catching fruit displays at the front of school cafeterias to nudge students to pick fruit. While behavioral economics has proven quite useful in certain interventions (increasing organ donation rates, medication adherence via reminders or small rewards, etc.), as a framework for explaining health inequities it is limited and sometimes criticized. Nudge theory tends to treat all individuals as somewhat uniform in their susceptibilities to biases. It doesn’t inherently address why some populations might have systematically different behaviors – except to say everyone has cognitive quirks. Critics argue that focusing on nudges downplays structural causes of poor health and inequality. For instance, if the problem is that low-income populations have worse diets, a behavioral economist might suggest nudging them via better food labeling or rearranging grocery stores. But this sidesteps issues like food affordability, marketing of junk food in poor areas, or the stress that drives comfort eating – deeper causes of the disparity. In fact, nudge approaches can sometimes come off as paternalistic or technocratic, implying that the root problem is individuals’ decision errors rather than a lack of options or unfair conditions. As one critical analysis noted, the ideology behind some nudge strategies insinuates “the root cause of health inequality is not systemic but individual – the cognitive flaws of the ‘less sophisticated’”. This essentially blames disadvantaged people for making irrational choices and prescribes nudging them to be “smarter” consumers. This is clearly a problematic stance, ignoring how unequal contexts shape choices. Another limitation: Nudges often assume a baseline of available choices – nudging works if the healthier choice exists to be nudged towards. In communities with very limited healthy options (like no nearby clinics or healthy food stores), you can’t nudge what isn’t there. So behavioral economics doesn’t fix lack of infrastructure or resources. It is better at fine-tuning decisions in contexts where multiple options exist. For inequities, the risk is focusing on micro-design of choices for the poor rather than giving them better choices to begin with. While behavioral economics acknowledges humans are not perfectly rational (which is a step beyond classical economics that treated any disparities as presumably rational outcomes), it still largely treats the problem at the decision-making level. It can explain some disparities in uptake of interventions or adherence – maybe more disadvantaged folks respond differently to incentives or have different present-bias (focus on immediate needs) because of scarcity mindsets. These insights are valuable (like understanding that poverty itself changes decision processing). However, those insights ultimately point back to alleviating poverty and stress, not just nudging behavior. In sum, Behavioral Economics and Nudge Theory rank low for explaining health inequities: they can tweak behaviors at the margins and provide clever interventions, but as an explanatory framework they avoid systemic analysis and can inadvertently perpetuate the notion that the main issue is individuals’ biased choices rather than unfair systems. Many have argued that nudges are a “poor substitute” for structural changes in addressing life-or-death matters. Therefore, while useful within a comprehensive strategy, they are among the least effective stand-alone theories for understanding why health inequities exist.

43. Moral Injury Theory

Moral Injury originally comes from psychology/psychiatry, referring to the mental, emotional, and spiritual distress that occurs when a person perpetrates, witnesses, or fails to prevent actions that deeply violate their moral or ethical code. It’s been studied especially in soldiers (e.g., a soldier feeling profound guilt and trauma for actions in war that contravened his values) and in professions like healthcare (clinicians feeling moral injury when systemic pressures force them to act against patients’ best interests or their own professional ethics). While moral injury is an important concept for the mental health of individuals in certain contexts, as a theory to explain population health inequities, it is not very applicable. Health inequities are differences in health outcomes across social groups, whereas moral injury is about inner conflict and trauma from moral transgressions or betrayals. One could stretch the concept slightly: perhaps chronic exposure to violence or participating in survival activities that conflict with personal morals (like crime born of poverty) could cause moral injury in marginalized communities, indirectly affecting their mental and even physical health (through stress). Or one might say healthcare providers in under-resourced settings experience moral injury from being unable to provide adequate care, which could contribute to burnout and reduced care quality in those settings (thus affecting health inequities). But those are tangential and not how the theory is normally used. Moral Injury Theory does not address core drivers of why, say, low-income people have more diabetes or Black women higher maternal mortality. It doesn’t consider social determinants, access issues, or discrimination directly. At best, it is relevant for specific sub-issues: for instance, perhaps public health workers themselves facing the reality of inequity feel a sort of moral injury (knowing preventable suffering occurs that they can’t stop due to systemic barriers). But that again describes the psychological impact on the worker, not an explanation of the disparity’s cause. If anything, moral injury might be seen as an outcome some individuals in inequitable systems experience (like a doctor in a rural clinic forced to ration care might suffer moral injury), rather than an explanatory cause of inequity. Thus, it ranks among the least effective frameworks for explaining health inequities. It wasn’t designed for that purpose, and its focus is misaligned with the population-level, structural nature of health disparities. Using moral injury to explain inequities would be stretching it beyond its domain. In contrast to everything else on this list, it’s not a public health or social theory at all, but a psychological aftermath phenomenon. Therefore, while moral injury is significant in its own right (especially for caring professions and veterans), it offers virtually no direct explanatory power regarding why some groups are healthier than others across society. It is placed at the bottom tier for this context.

44. Rational Choice Theory

Rational Choice Theory assumes that individuals make decisions by rationally weighing costs and benefits to maximize their utility. In classical economics and some social sciences, it’s posited that people act out of self-interest with full information and in a way that optimally benefits them (subject to their preferences). When applied to health behaviors or policy, a strict rational choice view would imply that if people are making “unhealthy” choices, it’s because the perceived benefits outweigh costs for them, given their preferences. Perhaps they value immediate pleasure from smoking more than potential future health, for example, and they act accordingly – rationally for their value system. This theory is highly problematic for explaining health inequities. It effectively ignores the structural and irrational factors that we know drive many disparities. It would imply that, in a free market of choices, any differences in health outcomes are due to differences in preferences or information. For instance, if low-income communities have worse diets, rational choice might say it’s because they prioritize cheaper, tasty calories over health – essentially blaming their preferences or knowledge. It completely misses how constraints shape choices: limited income, lack of grocery stores, targeted junk-food advertising, high stress, etc. Those constraints mean that choices are not made in a vacuum of rational calculation with equal opportunity. Rational choice theory also presumes an unrealistic level of information and computational ability that people often don’t have (which is why behavioral economics arose to critique it). It doesn’t account for addiction, habits, peer pressure, or misinformation – all of which are unevenly distributed or influenced by social factors. In an inequity context, rational choice can lead to a “blame the victim” or “market justice” mentality, suggesting that people in poor health must have made rational but unfortunate choices to trade health for other things, so that’s on them. This is both descriptively and morally suspect. It was perhaps implicitly how some policies treated the poor in the past (if they don’t go to the doctor, it’s because they chose to spend money elsewhere, etc.), which we now understand is a flawed lens. Rational choice doesn’t incorporate discrimination or power asymmetries either. It cannot explain why certain groups systematically have fewer real choices. From a rational actor perspective, if minorities receive poorer care, one might absurdly argue doctors are just rationally responding to some cost/benefit – which obviously is not an acceptable or accurate explanation; biases and systemic issues are at play. In truth, health inequities arise largely from structural forces that limit or heavily bias the “choices” available to different people – something rational choice theory cannot capture because it assumes a level playing field of choice. Given the modern understanding of health determinants, Rational Choice Theory is arguably the least adequate framework in this domain. It not only fails to explain inequities; if applied blindly, it can justify them as outcomes of individual preferences rather than injustices to be addressed. Public health has largely moved away from this thinking, recognizing that expecting purely rational health decisions in an irrational world is folly. In summation, rational choice theory ranks at the very bottom for explaining health inequities – it is simply the wrong tool, one that overlooks the core issues of structural inequality, and its simplistic assumptions can do actual harm by obscuring real causes.

Second Essay - Initial Ranking (PHL #4)

By OpenAI 4o

Introduction: Effectiveness in explaining health inequities depends on how well a theory addresses the structural and social root causes of disparities versus focusing narrowly on individual behaviors or biology. Theories that foreground systemic factors (like racism, class inequality, or policy) tend to better explain unfair differences in health outcomes across populations. In contrast, approaches that ignore social context or place all responsibility on individual choice often fail to account for why certain groups consistently have worse health (these theories rank lower). Below, the listed frameworks and models are ranked from “best” to “worst” in terms of how powerfully and comprehensively they explain health inequities. (The top-ranked theories explicitly consider social determinants, power structures, and historical context, whereas the lowest-ranked theories assume health is mainly a matter of personal or biological factors, overlooking broader inequities.)

1. Social Determinants of Health (SDOH) Theory: Top-ranked, this framework centers on the social, economic, and environmental conditions that shape health, which is fundamental to understanding health disparities. It recognizes that factors like poverty, education, housing, and racism drive differences in health outcomes much more than individual biology or medical care. Because SDOH focuses on structural causes of poor health (e.g. living in a polluted neighborhood or lacking access to healthy food), it directly addresses why marginalized groups experience worse health. In fact, the WHO emphasizes that addressing social determinants is essential for reducing health inequities, since these unfair conditions “have a powerful influence on health inequities” and often outweigh genetics or personal behaviors. By treating health inequities as a product of unequal social environments and resources, SDOH provides a comprehensive explanation for health gaps between groups.
   
   

2. Fundamental Cause Theory (Link & Phelan): This influential theory posits that socioeconomic status (SES) and other key social factors are “fundamental causes” of disease disparities. It explains that people with higher SES consistently enjoy better health because they have more “flexible resources” (money, knowledge, power, social connections) to avoid risks and adopt new health-improving innovations. Crucially, Fundamental Cause Theory accounts for why health inequities persist even as diseases change: those with social advantage can always leverage their resources to maintain a health edge. This theory is widely regarded as one of the most powerful explanations for health inequalities. By focusing on entrenched resource inequalities, it highlights structural drivers (like income inequality and education gaps) as the root of persistent health disparities, making it extremely effective in explaining inequities.
   
   

3. Intersectionality Theory: Intersectionality provides a critical, nuanced lens by examining how multiple axes of identity and oppression overlap to produce health inequities. Rather than looking at race, gender, class, etc. in isolation, intersectionality shows that people at the intersection of multiple marginalized identities (e.g. Black women, LGBTQ+ immigrants) often face compounded disadvantage in health. This theory elucidates the complex ways that systems of racism, patriarchy, classism and other oppressions interact to create unique health challenges. For example, an intersectional approach reveals how a low-income woman of color’s health is affected not just by socioeconomic status or race alone, but by their combined effects in society’s power structure. Because it forefronts power dynamics and overlapping inequalities, intersectionality is extremely effective in explaining why certain subgroups experience the worst health outcomes. It also pushes public health to address the “relationships between oppression and privilege” across all levels (individual, institutional, structural) to advance health equity.
   
   

4. Public Health Liberation (PHL): PHL is a new transdisciplinary theory explicitly designed to accelerate health equity. It synthesizes ideas from critical race theory, feminist theory, anti-racism, political economy, and community advocacy into a comprehensive framework for dismantling health inequities. Public Health Liberation argues that we must view the entire “public health economy” through a justice lens to expose the contradictions that reproduce vast inequity. It emphasizes community leadership, “liberation” from oppressive systems, and even introduces concepts like “public health realism” (pragmatic strategies within existing power structures) and “liberation safe spaces”. Because PHL explicitly targets structural drivers (e.g. institutional racism, class exploitation) and calls for empowering marginalized communities, it offers a bold and holistic explanation of health inequity. In essence, it challenges conventional public health approaches and insists on radical changes to eliminate systemic inequities in health. (As an emerging framework, PHL shows great promise by directly addressing power and oppression in public health.)
   
   

5. Critical Race Theory (CRT) in Public Health: Adapted from legal scholarship, CRT in public health examines how racism is embedded in laws, policies, and institutional practices that shape health. It holds that racial health disparities are not due to individual behavior or innate differences, but result from structural racism – the historical and ongoing societal forces that privilege one race over others. CRT is extremely effective for explaining racial health inequities because it identifies mechanisms like residential segregation, discriminatory policies, and biased medical practices as root causes of poorer health in communities of color. Key tenets include understanding race as a social construct (not a biological reality) and recognizing that racism operates at a systemic level beyond individual acts. Public health experts note that CRT’s tenets are essential to addressing large racial health gaps – without incorporating CRT’s insights, efforts to tackle disparities will miss the fundamental drivers. By providing an anti-racism lexicon and paradigm, CRT helps researchers and practitioners to name and confront structural racism in health systems, making it an invaluable framework for health equity.
   
   

6. Anti-Racism Frameworks: These approaches complement CRT by focusing on actively dismantling systemic racism and promoting racial equity in health. Anti-racism frameworks in public health call out racism as a root cause of disparities and emphasize structural interventions (policy changes, power shifts) over blaming individual “cultural” behaviors. For example, an anti-racist public health approach might advocate for redistributing resources to minority neighborhoods, reforming racist policies, and ensuring representation of marginalized groups in decision-making. Such frameworks assume that eliminating health inequities requires deliberate anti-racist action – simply being “not racist” is insufficient. By explicitly targeting structural racism (in housing, education, healthcare, criminal justice, etc.), anti-racism frameworks provide a direct explanation and remedy for racial health inequities. They are effective because they address the underlying power imbalances and discriminatory structures that cause, for instance, Black Americans to have higher infant mortality or lower life expectancy. (In short, racism is identified as a public health crisis, and these frameworks guide efforts to uproot it – thereby explaining and tackling a major source of health inequity.)
   
   

7. Ecosocial Theory (Nancy Krieger): The ecosocial theory offers a unifying, biologically-informed explanation of health disparities by showing how social injustice literally “gets under the skin.” It posits that individuals embody their social and physical environments over time, meaning the harms of racism, poverty, sexism, etc. become biologically expressed as illness and premature death. Key constructs of ecosocial theory include embodiment, pathways of embodiment, cumulative lifetime exposure, and accountability for inequity. In practice, this theory examines how oppressive social systems (like a racist society or exploitative economy) create unequal living conditions, which then lead to different disease risks that are literally absorbed into our bodies (for example, chronic stress from discrimination contributing to hypertension in marginalized groups). Ecosocial theory is highly effective in explaining inequities because it integrates social and biological factors: it recognizes that inequitable social conditions are not “natural” but are imposed by systems of power, and these conditions produce the unequal distribution of disease. By challenging “biomedical individualism” (the false idea that health is purely personal or genetic), ecosocial theory provides a robust framework for understanding health inequities as the outcome of entrenched social hierarchies interacting with human bodies over time.
   
   

8. Feminist Theory in Public Health: Feminist theory examines how gender inequality and patriarchy contribute to health disparities, especially those affecting women and gender-diverse people. It highlights issues like unequal power dynamics in relationships, gender-based violence, reproductive rights, and occupational sexism as factors that negatively impact health. This perspective is effective in explaining inequities because it shows that many health issues (from maternal mortality to mental health burdens) are rooted in gender-based power imbalances and social roles, not just individual choices. For instance, a feminist public health analysis would note that women’s higher rates of certain health problems can stem from systemic factors like lower socioeconomic status, unpaid caregiving burdens, lack of political voice, or exposure to gender violence – all manifestations of patriarchy. By advocating for gender-sensitive interventions and equity for all genders, feminist theory expands our understanding of health inequities beyond a one-size-fits-all approach. It essentially argues that gender justice is health justice, making it a crucial framework for explaining why, for example, women of color or transgender individuals face unique health challenges due to intersecting sexism and other oppressions.
   
   

9. Structural Violence Theory (Galtung/Farmer): Structural violence refers to the indirect harm caused by unjust social, economic, and political systems. This theory powerfully explains health inequities by showing how institutions and policies – rather than individual actions – systematically put certain populations “in harm’s way”. For example, laws and economic arrangements that produce extreme poverty, racial segregation, or lack of access to healthcare are forms of violence that quietly but profoundly damage health. Paul Farmer and others have illustrated that “large-scale social forces – racism, gender inequality, poverty, political violence – often determine who falls ill and who has access to care”. Structural violence theory is highly effective in explaining inequities because it frames issues like high infant mortality in marginalized communities or shorter lifespans of the poor as neither random nor purely biological, but as the predictable result of structural oppression. It shifts focus from individual behaviors to the “social arrangements that are embedded in the political and economic organization of society”, which cause injury to people by denying them basic needs. In short, this theory asserts that many health disparities are a form of violence inflicted by societal structures – a perspective that is critical for understanding and addressing root causes of inequity.
   
   

10. Structural Vulnerability Theory: Closely related to structural violence, this theory examines how hierarchical social structures (like class, race, immigration status) create differential vulnerability to illness and injury. It recognizes that people are “structurally vulnerable” when they belong to groups that society marginalizes – for instance, undocumented immigrants, the homeless, or Indigenous peoples under colonial systems. Their heightened health risks are not due to inherent traits or choices, but due to structural factors: e.g. unstable housing, exposure to exploitative labor, lack of political rights, or constant stigma. Structural vulnerability theory effectively explains health inequities by pinpointing how societal arrangements (laws, economic policies, social hierarchies) produce vulnerability. It goes beyond individual risk factors and looks at one’s position in social power structures. For example, a low-wage migrant worker might be structurally vulnerable to workplace injuries and poor health because labor laws exclude them and healthcare is inaccessible – their poor health is a predictable outcome of their social position, not personal failings. By analyzing these built-in disadvantages, this framework underscores that to understand health disparities, we must examine how vulnerability is socially produced by inequitable structures.
    
    

11. Political Economy of Health: This perspective (often called the “social production of disease” model) explains health inequities by analyzing how economic and political systems distribute resources and risks in society. It emphasizes that under systems like capitalism, priorities of wealth accumulation and power produce health disparities – for example, when profit motives lead to environmental pollution in poor areas or when labor policies favor exploitation over worker safety. The political economy approach argues that health is largely determined by the political and economic choices a society makes: who has access to good jobs, education, safe housing, clean water, and healthcare? Inequities arise because these goods are not distributed fairly. This framework is very effective in explaining inequities because it situates health outcomes within broader power relations and class structures. It identifies how policies (taxation, welfare, healthcare financing) and global economic forces (like trade agreements or austerity measures) can create or mitigate health disparities. By focusing “upstream” on structural drivers (instead of “downstream” individual behaviors), the political economy of health perspective reveals that many health inequalities are policy-driven and thus avoidable. It also often calls for “healthy public policies” (like redistributive measures to reduce poverty) as solutions, reinforcing the idea that political choices are fundamental causes of health inequity.
    
    

12. Marxist Theory (as applied to health): A Marxist analysis attributes health inequities to class struggle and the dynamics of capitalism. It views ill-health among the working class and poor as a direct outcome of exploitation and material deprivation imposed by capitalist modes of production. For example, from a Marxist perspective, the high rates of industrial injuries or chronic diseases in laborers come from profit-driven neglect of worker safety and the selling of unhealthy products (tobacco, junk food) for profit. This theory effectively explains inequities by highlighting economic class as a central axis of health: under capitalism, the wealthy (who control capital) enjoy better health, while the working class and unemployed suffer worse health due to low wages, unsafe living conditions, and limited access to care. It also emphasizes how healthcare itself can become a commodity accessible mainly to those who can pay, further entrenching disparities. In essence, Marxist theory casts health inequities as an expected consequence of a system that puts profits over people – reflecting Engels’ notion of “social murder” (below) – where the structure of the economy systematically harms the health of the oppressed classes. This class-centered, anti-capitalist lens strongly explains why we see persistent health gaps aligned with socioeconomic class and why meaningful progress may require structural change in economic relations.
    
    

13. Social Murder Concept (Engels): Originating from Friedrich Engels in the 19th century, “social murder” describes how the living and working conditions imposed on the poor by the wealthy lead to early death. Engels observed that the squalid housing, dangerous workplaces, and meager wages of the industrial working class in England caused illness and mortality—outcomes which were effectively “murder” by the social order, since they were preventable results of exploitation. This concept bluntly explains health inequities as a form of systemic killing: when society allows extreme inequality, it is effectively condemning disadvantaged groups to suffer and die prematurely. The social murder idea remains sadly relevant; for instance, when low-income communities today have far shorter lifespans due to poverty, substandard housing, and pollution, it is a result of systemic choices (not personal failings) that can be viewed as a form of violence by the ruling class. As an explanatory framework, social murder is powerful (if provocative) because it underscores moral responsibility for health inequities – implying that those in power who maintain unjust conditions are culpable for the resulting deaths. It aligns with modern discussions of structural violence and fundamental causes, offering a grim but clear explanation: extreme health disparities are the lethal result of social injustice.
    
    

14. Critical Public Health: This is not a single theory but a perspective that critically examines public health itself, questioning mainstream assumptions and centering issues of power, justice, and inequality. Critical public health scholars argue that traditional public health too often focuses on individual behaviors or biomedical solutions while overlooking the structural drivers of poor health. By contrast, a critical public health approach emphasizes that health interventions and research should address social oppression, economic inequality, and the voices of marginalized communities. It explains health inequities by shining a light on how conventional practices might inadvertently sustain inequities (for example, if public health campaigns ignore that not everyone can “choose” healthy foods due to food deserts, or if data systems hide racial disparities). In sum, critical public health is effective in explaining inequities because it questions the status quo: it asks “who benefits from current health policies?” and “whose perspectives are missing or silenced?”. It brings in theories like political economy, critical race theory, feminism, etc., into public health discourse. This perspective reminds us that public health is inherently political and that inequities persist in part because power structures—including those within public health institutions—need transformation.
    
    

15. Critical Medical Anthropology: This approach applies anthropological methods and critical theory to understand how power and inequality shape health, illness, and healthcare. It goes beyond the biological and cultural explanations of disease by examining political-economic contexts (colonialism, capitalism, globalization) and how they affect communities’ health. For example, a critical medical anthropologist might study how global trade policies make essential medicines unaffordable in poor countries, or how cultural narratives imposed by Western biomedicine can marginalize indigenous healing systems and contribute to inequity. This theory effectively explains health disparities by providing a “ground-up” view of structural forces: through ethnographic insight, it shows how the lived experience of illness in marginalized groups is tied to larger structures (like neoliberal economic reforms or racialized social hierarchies). It also critically analyzes healthcare systems themselves as institutions that can reproduce inequality (e.g., through unequal access or cultural insensitivity). By foregrounding colonial history, power relations, and economic exploitation in health, critical medical anthropology offers a deep explanation for why certain populations (often those oppressed or colonized historically) suffer worse health outcomes. It essentially merges macro-level critique with on-the-ground evidence of inequality’s toll on human bodies.
    
    

16. Social Justice Theory in Public Health: This framework treats health as a matter of social justice, insisting that everyone has an equal right to health and that inequities are fundamentally ethical and political problems. It explains health disparities by asserting that they result from injustices – such as racism, economic inequality, sexism, and other forms of discrimination – that unfairly advantage some and disadvantage others. In other words, health inequities are viewed as evidence of societal failure to distribute opportunities and resources fairly. The social justice approach is effective in explaining inequities because it explicitly names them as “unfair and avoidable differences” caused by human decisions (not natural or inevitable). It calls attention to policies and norms that systematically deprive certain groups of the conditions needed for health (like safe housing, quality education, or political voice). By framing health equity as a justice issue, this theory galvanizes action to change those policies and norms. Importantly, it invokes principles of human rights and ethics: for example, it would say it is unjust that life expectancy is drastically lower for people in poverty or for Black Americans, and thus society has a moral obligation to reform the structures causing that gap. In sum, social justice theory explains inequities by linking them to inequitable social arrangements, and it underlines that achieving health equity is a matter of justice, not charity.
    
    

17. Health Equity Frameworks: “Health equity” frameworks are practical guides or models that help design policies and interventions to reduce disparities by tackling structural determinants. These frameworks are grounded in the idea that special efforts and systemic changes are needed to correct inequities. For example, a health equity framework might involve systematically assessing how any new program impacts vulnerable groups, or ensuring proportionate resource allocation to those with worse health (“proportionate universalism”). While not a single theory, these frameworks are effective in explaining inequities because they keep focus on structural and social drivers – reminding practitioners that differences in health are rooted in unequal social conditions. They often incorporate concepts from SDOH, justice, and human rights. Essentially, health equity frameworks operate on the premise that to achieve equal health outcomes, we must recognize and address unequal starting positions (e.g., some communities have faced historic disinvestment, discrimination, etc.). They guide action by asking: “How will this reduce (or inadvertently widen) health gaps between groups?” In doing so, they reinforce explanations of inequity that center on fixing systemic imbalances (rather than blaming individuals or purely treating diseases).
    
    

18. Life Course Theory: Life course theory explains health inequities by looking at how advantages or disadvantages accumulate from gestation through old age, often compounding over generations. It posits that early-life experiences, exposures, and social contexts have lasting impacts on an individual’s health trajectory. For example, adverse conditions in childhood (poor nutrition, toxic stress from poverty or discrimination, limited education) can lead to greater risks of chronic disease in adulthood – thereby partly explaining why those born into disadvantaged families tend to have worse health as adults. This theory is effective for explaining inequities because it shows that health disparities are not just a snapshot in time; they are the product of long-term and even intergenerational processes. Marginalized groups often face cumulative adversity (e.g., a child in a low-income, segregated neighborhood may face lead exposure, attend under-funded schools, and experience discrimination – all of which set the stage for poorer health decades later). Life course theory also highlights critical periods (like in utero, early childhood, adolescence) where interventions can make a big difference in breaking the cycle of inequity. By emphasizing timing and trajectory, it explains why simply addressing adult behaviors isn’t enough – we must consider the lifelong and cross-generational pathways that create health gaps.
    
    

19. Theory of Health Inequity Reproduction (THIR): THIR examines how health disparities persist or widen over time and across generations, essentially analyzing the mechanisms by which inequities are continually “reproduced” in society. It builds on the idea that without structural change, the children of marginalized groups often inherit the same disadvantages as their parents, thus experiencing similar health issues. THIR might incorporate elements of fundamental cause (e.g., how wealth and knowledge are passed down) and life course theory (e.g., how early disadvantages lead to later outcomes), but it specifically zeroes in on reproduction of inequality. This theory is effective in explaining why, despite decades of medical progress, the same social groups remain on the bottom of health statistics. It would point to factors like ongoing residential segregation, educational inequities, or institutional racism in healthcare that continually re-create unequal conditions. For example, THIR could explain how Black Americans continue to have higher maternal mortality rates generation after generation due to persistent structural racism in healthcare and society. By mapping these feedback loops and structural continuities, THIR underscores that health inequities are not static – they are actively maintained by societal structures unless we intervene in those structures.
    
    

20. Historical Trauma Theory: This theory is particularly used to explain health disparities in indigenous and other historically oppressed communities by examining the long-term health effects of collective traumatic events (such as colonization, genocide, slavery, war, forced relocation). It posits that trauma is not just experienced by individuals but can be transmitted across generations, affecting the health behaviors and outcomes of descendants. For instance, the theory has been applied to Indigenous populations in North America to explain high rates of substance abuse, mental health issues, and chronic disease as outcomes of the unresolved grief and stress from colonization and cultural suppression. Historical trauma theory is effective in explaining inequities because it links present-day health to historical injustices – showing that the past is not really past when it comes to health. It helps make sense of why communities that suffered massive trauma (and are often still socioeconomically marginalized) have distinctive health challenges. This theory encourages culturally-informed healing practices and structural changes as remedies, rather than simply biomedical treatment. It reminds public health practitioners that to understand disparities, we must consider historical context: many health inequities have roots in traumatic historical events that continue to echo through community health today.
    
    

21. Liberation Theology (applied to health): Liberation theology is a movement originally within Christian theology that emphasizes social concern for the poor and oppressed, positing that addressing their plight is a moral and spiritual duty. In a public health context, it inspires an approach that views health equity as a moral imperative and aligns efforts to eliminate health inequities with principles of liberation and justice (often faith-inspired). It is effective in explaining inequities in a moral frame: health disparities are seen as a result of “sinful” social structures (oppression, exploitation) that must be changed in favor of the poor and marginalized. Liberation theology-influenced public health might, for example, highlight how Jesus’s ministry to the sick and outcast translates into modern calls for preferential options for the poor in healthcare. While not a scientific theory per se, it provides a powerful ethical explanation: inequities are fundamentally against God’s will (or against fundamental moral law), produced by human greed and oppression. By framing the elimination of health inequity as part of liberating the oppressed, it motivates community empowerment and aligns with movements for structural change. In Latin America and elsewhere, this perspective has historically fueled community health initiatives and calls for addressing the “root causes” of illness (poverty, injustice) as part of spiritual liberation.
    
    

22. Postcolonial Theory (as applied to health): Postcolonial theory examines how the legacy of colonialism – the long history of subjugation and exploitation of colonized nations and peoples – continues to shape present realities. Applied to health, it explains inequities especially between (and within) countries by highlighting colonial and neocolonial power dynamics. This might involve analyzing how colonial-era extraction of resources, destruction of local economies, suppression of cultures, and imposition of foreign governance left formerly colonized regions with enduring poverty and weak health systems, leading to worse health outcomes. It also critiques how global health can sometimes have a colonial mindset (e.g. Western experts imposing solutions without local context). Postcolonial theory effectively explains inequities by pointing out that global and domestic health disparities are not accidents of fate; they are the outcome of historical and ongoing exploitation. For example, why does a country in the Global South have lower life expectancy and higher disease burden? A postcolonial analysis might show it’s related to centuries of resource extraction, arbitrary borders causing conflict, and current global trade inequalities – a direct line from colonialism to current health crises. Similarly, within countries, postcolonial perspectives highlight how Indigenous populations or racial minorities face worse health due to historical oppression and continued marginalization. By centering colonial history and power imbalances, this theory adds a crucial explanatory layer for many health inequities worldwide.
    
    

23. Queer Theory in Public Health: Queer theory, arising from critical studies of sexuality and gender, questions normative assumptions about sexuality and challenges the rigid categorization of identities. In public health, it is applied to understand and address health disparities affecting LGBTQ+ communities. Queer theory explains these inequities by revealing how heteronormativity (the assumption that heterosexual, cisgender identities are the default or “normal”) is built into social institutions, including healthcare systems, laws, and research. This can lead to invisibility, stigma, and discrimination against LGBTQ+ people, which in turn harm their health. For example, queer theory would highlight how a lack of culturally competent care or anti-LGBTQ policies (like denial of gender-affirming care or marriage inequality) directly contribute to mental health issues, higher HIV rates, or suicide risk in these communities. It’s effective in explaining inequities because it illuminates that the health problems of queer and trans people are not because of their identities per se, but because of society’s treatment of those identities (stigma, violence, exclusion). By deconstructing what is considered “normal,” queer theory also encourages public health to collect better data on sexual/gender minorities and to design interventions that affirm queer identities. In essence, it brings an equity lens that validates LGBTQ+ experiences and identifies structural homophobia and transphobia as key causes of health disparities.
    
    

24. Capabilities Approach (Sen & Nussbaum): The capabilities approach is a human development framework that can be applied to health: it focuses on what genuine opportunities or “capabilities” individuals have to achieve well-being. Rather than just measuring resources or outcomes, it asks: do people have the freedom and means to lead a healthy life they value? In explaining health inequities, this approach points out that marginalized groups often lack basic capabilities (due to factors like poverty, discrimination, lack of education). For instance, one’s capability to be healthy can be constrained by not having access to nutritious food, clean water, or healthcare. The capabilities approach is effective in that it shifts the discourse to equity of opportunities – two people may have the same “right” to health on paper, but if one lives in a violent neighborhood with no clinics and the other in a wealthy suburb, their real freedoms to achieve health are unequal. It emphasizes expanding capabilities (e.g., improving education, empowerment, social support) as a way to reduce disparities. While somewhat philosophical, it provides a moral and practical explanation: health inequities exist because society fails to ensure all its members have the substantive freedoms (capabilities) to be healthy. By framing health as an issue of freedom and human flourishing, it aligns with equity-focused policy-making (ensuring everyone has the means to achieve health, not just nominal access).
    
    

25. Human Rights-Based Approach: This approach treats health as a fundamental human right, meaning that everyone is entitled to the highest attainable standard of health without discrimination. It explains health inequities by identifying where rights are being violated or not fulfilled. For example, if a certain population lacks access to clean water or basic healthcare, a human-rights perspective frames that not just as a disadvantage but as a violation of their rights. This approach is effective in highlighting inequities because it sets a clear, non-negotiable standard: disparities (like poorer health outcomes for certain racial or socioeconomic groups) signal that society is failing to uphold the right to health for all. It also emphasizes accountability – governments and institutions have obligations to respect, protect, and fulfill the right to health by addressing discrimination and inequitable conditions. The human rights-based approach often brings legal and ethical weight to discussions of health inequity, pressuring policymakers to enact changes (for instance, expanding universal healthcare or ensuring equitable distribution of resources) as a matter of duty, not just policy preference. In summary, it explains health disparities by pointing to systemic failures in guaranteeing human rights, and it bolsters efforts to eliminate inequities through a universally accepted moral framework.
    
    

26. Community-Based Participatory Research (CBPR): CBPR is a research approach rather than a causal theory, but it’s critical for advancing health equity. It involves communities – especially marginalized ones – as equal partners in the research process to study and address health issues that affect them. While CBPR itself doesn’t “explain” why inequities exist, it is predicated on the understanding that traditional research often ignores the voices and context of oppressed communities, leading to incomplete explanations. CBPR helps explain and tackle inequities by ensuring that the lived experiences of those facing disparities inform the analysis of causes. For example, by engaging a low-income neighborhood in researching local asthma rates, CBPR might uncover contributing factors that outsiders overlooked (like a specific local polluter or housing conditions). It empowers communities to identify structural issues (poor infrastructure, lack of services, discrimination) and ensures interventions are culturally appropriate. In essence, CBPR operates on the recognition that health inequities are best understood and addressed with the knowledge of the affected communities – because they often know which systemic barriers are most harmful. As a result, CBPR leads to more effective explanations (and solutions) for disparities, bridging the gap between academic theory and on-the-ground reality.
    
    

27. Community Organization Theory: This theory underlies many grassroots public health initiatives, focusing on how communities can organize and empower themselves to identify and solve health problems. It’s based on principles of participation, leadership development, and collective action. While it doesn’t directly explain the original cause of inequities, it implicitly acknowledges that powerlessness and lack of organization are part of why inequities persist. By empowering communities – especially those marginalized – to demand resources or policy changes, it addresses the inequitable distribution of power. For instance, community organization might involve residents lobbying the city for clean water or safer streets, thereby overcoming a structural neglect that caused their health issue. This approach explains inequities to some extent by demonstrating that when communities have the tools to organize, they can counteract external forces that created the inequity (like political disinterest or discrimination). It’s most useful for showing that solutions to health inequities require shifting power to communities, and it often reveals inequitable structures during the process (e.g., discovering that no health clinic was built in a neighborhood due to systemic racism and then organizing to change that). In short, community organization theory highlights the role of community empowerment (or lack thereof) in perpetuating or reducing health disparities.
    
    

28. Hegemony Theory (Gramscian): Hegemony theory deals with how dominant ideologies and cultural norms maintain the power structure. In health, a Gramscian analysis suggests that the ideas promoted by the elite (e.g., the notion that health is solely an individual responsibility or that poverty is due to personal failings) become accepted by society, even by those disadvantaged. This “common sense” can obscure the structural causes of health inequities. For example, if society largely believes that anyone can be healthy if they just work hard and make good choices, that hegemonic narrative blames individuals and hides how inequitable conditions limit people’s choices. Hegemony theory is effective in explaining an aspect of health inequity: it clarifies why inequities can persist without revolt – because the oppressed might internalize or at least acquiesce to explanations that justify the status quo (“that neighborhood is unhealthy because the people there don’t take care of themselves,” etc.). It points out that public health policies often reflect the interests of the powerful, and alternative perspectives (like those of marginalized groups) are sidelined. Understanding hegemony helps explain why certain harmful policies (like low social spending or punitive welfare rules) can continue – the ruling class’s worldview dominates the discourse. Therefore, this theory adds to our understanding of inequities by highlighting the role of ideas, narratives, and ideology in sustaining or challenging unequal health outcomes.
    
    

29. Elite Theory (in health policy): Elite theory posits that society is controlled by a small group of elites (political, economic, bureaucratic) who make decisions in their own interest, often at odds with the needs of the masses. Applied to public health, it suggests that health policies and resource allocations often reflect the preferences of powerful elites rather than the greatest needs. This can explain health inequities by revealing how, for example, expensive high-tech medical innovations receive funding (benefiting corporations or affluent patients), while basic public health infrastructure in poor communities is neglected. If elites are not affected by certain health problems (e.g., diseases of poverty), those issues may get less attention or investment. Elite theory thus effectively explains disparities as a consequence of power imbalances in decision-making: those with wealth and influence shape health systems to serve their interests first. It also sheds light on why truly equity-promoting policies (like universal healthcare or aggressive poverty reduction) often face political resistance – they may threaten elite advantages or require redistribution. In sum, elite theory helps us see that health inequities persist partly because those in power benefit (or at least are not inconvenienced) by the status quo, and they have the means to maintain it. Recognizing this can underscore the need for broader democratic participation and accountability in health policy to achieve equity.
    
    

30. Internalized Oppression Theory: This concept explores how members of marginalized groups may internalize negative societal beliefs and stereotypes about themselves, leading to psychological and behavioral impacts that can harm their health. Essentially, oppression can “get under the skin” not just via external deprivation but by shaping how people see themselves. For instance, someone facing racism constantly might begin to believe they are less worthy of good health or may cope with stress through harmful behaviors, fulfilling the oppressive stereotype. Internalized oppression theory explains a piece of health inequity by highlighting a vicious cycle: systemic oppression causes poor health outcomes, and those outcomes are worsened or maintained when the oppressed unconsciously adopt the oppressor’s view (like feeling hopeless or undeserving of care). This might manifest in phenomena such as internalized racism (leading to stress, hypertension) or internalized stigma among LGBTQ+ individuals (leading to depression or substance use). While internalized oppression is not the root cause (the root is the external oppression), it is an important mechanism that helps explain why inequities can be stubborn. It also signals that solutions must restore dignity, agency, and cultural pride in addition to removing structural barriers. In summary, this theory reminds us that the psychological imprint of oppression is one pathway by which social inequality translates into health inequality.
    
    

31. Urban Regime Theory: Urban regime theory examines how local coalitions of power (city government officials, businesses, developers, etc.) govern cities, often prioritizing economic growth and certain interest groups. Applied to health, it can explain inequities in urban settings by showing how the decisions of urban regimes benefit some neighborhoods or populations and neglect others. For example, an urban regime might focus on attracting affluent residents and businesses (investing in those districts), while low-income neighborhoods see less investment, leading to disparities in housing quality, pollution, and availability of services. This theory effectively explains local-level health inequities: why does one part of the city have parks, clinics, and clean streets while another has toxic waste sites and crumbling infrastructure? The answer often lies in who has influence at City Hall and whose needs align with the regime’s agenda. If the urban regime is dominated by elites with little representation from poor or minority communities, policies may perpetuate spatial health inequities (like food deserts or clinic closures in underserved areas). Urban regime theory highlights the importance of political power dynamics at the city level in shaping health determinants. It suggests that equitable health outcomes in a city require inclusive governance structures and political will to invest in all communities, not just those that align with the regime’s economic interests.
    
    

32. Political Realism (International Relations theory applied to health): Adapted from IR theory, political realism views nations (or actors) as driven by power and self-interest rather than moral considerations. In a global health context, this perspective explains international health inequities by noting that wealthy nations often act chiefly to protect their own interests, even in health matters. For example, during global pandemics or in distribution of medical aid, richer countries might hoard vaccines or prioritize diseases that could spread to them, rather than addressing the most lethal conditions in poorer countries. Realism would predict that global health initiatives often have ulterior motives (like diplomacy or economic gain) and that poorer countries’ health needs may be under-addressed unless they align with the interests of powerful states. This theory explains inequities between countries (and global inequities within countries) by highlighting the role of power and geopolitics: those with more power secure better health security and resources, while the health of people in less powerful states can be neglected on the world stage. It’s a somewhat cynical lens, but it does clarify why, for instance, some preventable diseases endemic in low-income countries receive scant funding (no powerful state feels threatened by them). Political realism underscores that without global solidarity or ethical leadership, health disparities will mirror global power imbalances. However, it also provides a practical viewpoint that can be used to design savvy strategies (like framing health aid as in nations’ enlightened self-interest) to get around pure power politics.
    
    

33. Health Impact Assessment (HIA): HIA is a tool for predicting and evaluating the potential health effects of policies or projects in sectors like housing, transportation, or education. While not a theory of causation, using HIA reflects an understanding that policies outside the health sector significantly shape health outcomes – often in inequitable ways. By systematically assessing how a proposed policy might affect different population groups, HIA helps uncover and explain potential inequities before they happen or worsen. For example, an HIA on a plan to close public transit routes might reveal that low-income and minority communities would disproportionately lose access to jobs and medical care, predicting a widening of health gaps. In this way, HIA contributes to explaining inequities by concretely linking social decisions to health consequences and identifying which groups are at risk. It operates on the same premise as social determinants frameworks: health is influenced by all policy areas. HIA’s focus on equitable decision-making (often including community input) means it actively seeks to prevent exacerbating disparities. Thus, while HIA itself doesn’t provide a new causal theory, it enforces a discipline of thinking about health inequities in all policies, illustrating how inequities can be created or reduced by policy choices. It’s an important practice that bridges theory and action in pursuit of health equity.
    
    

34. Health Impact Pyramid (Frieden): The Health Impact Pyramid is a model that ranks public health interventions by their population impact – with the base of the pyramid being interventions that address socioeconomic factors (broadest impact), and the top being counseling and education (smallest impact). This framework indirectly explains health inequities by illustrating that upstream factors (poverty, education, housing) have far greater influence on overall health than downstream factors (like individual treatment). For example, improving sanitation or reducing poverty can yield larger health gains (and narrow inequities) compared to only urging individuals to exercise more. By prioritizing interventions that reach entire populations (like policy changes, environmental improvements), the pyramid highlights that inequities are best addressed at the structural level (its base) where changes benefit everyone, especially the disadvantaged. Frieden’s model also suggests why exclusively clinical or individual-focused efforts often fail to eliminate disparities – they’re at the tip of the pyramid and require sustained individual behavior change, which is hardest to achieve and often least accessible to disadvantaged groups. In summary, the Health Impact Pyramid is a visual, practical embodiment of social determinants theory: it underscores that tackling fundamental social conditions yields the greatest and most equitable health improvements, thereby offering guidance that aligns with explanations of health inequity.
    
    

35. PRECEDE-PROCEED Model: This is a planning model for health promotion that includes assessing social, epidemiological, behavioral, and environmental factors (PRECEDE) and then implementing and evaluating interventions (PROCEED). While not inherently an equity theory, it provides a comprehensive structure to analyze health problems, including upstream determinants. In explaining inequities, PRECEDE-PROCEED guides practitioners to look at predisposing, enabling, and reinforcing factors in a community that contribute to health issues. For instance, in the PRECEDE phase one might identify that a high rate of diabetes in a community is not just due to individual diet (predisposing knowledge and attitudes), but also due to an environment with no grocery stores (enabling factor) and social norms around traditional foods (reinforcing factor). By requiring a social and environmental assessment before intervening, this model inherently acknowledges that context matters for health outcomes. It can thus highlight inequities – for example, comparing two communities during assessment might show one lacks health-enabling resources. PRECEDE-PROCEED’s systematic approach ensures that interventions are targeted not only at individuals but at changing environmental and policy factors if needed. So, it doesn’t “explain” inequities in a theoretical sense, but it accounts for them in program design, making it a valuable model for actually addressing the multiple layers (including structural) that cause disparities.
    
    

36. Ecological Systems Theory / Social Ecological Model: These related frameworks view health as the product of interactions across multiple levels – from individual to interpersonal, community, and societal levels. The social ecological model explicitly includes factors like policies, community infrastructure, and social norms as outer layers influencing inner layers (individual behavior). This multi-level perspective is useful in explaining inequities because it recognizes that people’s health behaviors and outcomes are shaped by the environments they live in. For example, an individual’s diet (individual level) is influenced by family and peers (interpersonal), by what grocery stores or restaurants are in the neighborhood (community), and by agricultural subsidies or food marketing regulations (policy level). Thus, differences in any of these layers across social groups can lead to health disparities. The ecological model effectively counters any notion that health disparities are simply due to personal choice – instead, it shows how systemic differences in environments produce different health outcomes. It doesn’t inherently critique power, but it provides a structure to incorporate structural factors (like access to care, or discrimination as a societal factor). Public health practitioners often use this model to ensure interventions address multiple levels (e.g., not just educate individuals, but also change community conditions), which is key to reducing inequities. In summary, the ecological approach explains inequities by mapping out the many contextual influences on health and demonstrating that unequal distribution of supportive vs. harmful factors at these levels leads to unequal health outcomes.
    
    

37. Biopsychosocial Model: The biopsychosocial model broadens the older biomedical model by stating that to understand health and disease, we must consider not just biological factors, but also psychological and social factors. It’s holistic, acknowledging that stress, social relationships, and community context can influence health. In terms of inequities, the biopsychosocial model is a step forward from a purely biomedical view (which would ignore social context entirely), but it does not explicitly tackle power or structural injustice. It can explain some differences – for instance, why someone in a socially stressful environment might have worse health outcomes (psychosocial pathways like chronic stress affecting the immune system). However, it tends to treat “social factors” in a general way and might not fully capture systemic inequities. Still, compared to models focusing only on biology or behavior, the biopsychosocial model better explains inequities by legitimizing the role of socioeconomic status, culture, and environment in health. It paved the way for later, more critical frameworks by establishing that illness is multi-factorial. For example, managing diabetes isn’t just about insulin (biological) or patient knowledge (psychological) – one must consider if the patient can afford healthy food and has social support (social factors). In conclusion, the biopsychosocial model recognizes social determinants but doesn’t necessarily delve into why those social factors are unequal; hence, it’s moderately effective in explaining health inequities, better than purely biomedical perspectives but not as pointed as structural theories.
    
    

38. Praxis Theory (Freire, Gramsci, Wainwright): Praxis refers to the cycle of reflection and action to change the world, a concept popularized by Paulo Freire in the context of conscientization (critical consciousness). In public health, praxis theory underlies approaches that engage communities in critical thinking about their conditions and empower them to act for change. It’s closely tied to liberationist and critical approaches. While again not a direct “cause of disease” theory, it explains inequities by highlighting the importance of critical awareness of oppression. According to this view, health inequities persist when communities have been denied the ability to question and transform their circumstances. Freirean praxis in health might involve, for example, poor community members analyzing why their neighborhood lacks sanitation and then organizing to demand those services. This theory is effective in addressing inequities because it treats the lack of power and voice among the oppressed as a key issue – and it directly works to change that by fusing education and activism (people learn about the structural reasons for their ill health and simultaneously work to change them). In short, praxis theory contributes to explaining inequities by pointing out that without active, conscious participation of the oppressed in liberation, inequities will continue. It implies that part of why inequities exist is because oppressive systems also shape knowledge and discourage critical awareness. Empowering people with critical consciousness is therefore a strategy to both explain and eliminate inequities by enabling collective action.
    
    

39. Health Lifestyles Theory (Cockerham): This sociological theory examines how patterns of health-related behavior (“lifestyles”) are shaped by one’s social context, especially class and group culture. It notes that people in similar social strata tend to have similar lifestyles (diets, exercise habits, smoking/alcohol use, healthcare utilization), which in turn affect their health outcomes. The theory argues these lifestyles are not just individual choices but are structured by life chances – resources, education, socialization, peer influences, etc., that come with one’s social position. For example, middle-class lifestyles might involve regular exercise and health check-ups due to more access and knowledge, whereas working-class lifestyles might include riskier behaviors, partly due to stress or norms and lower access to healthy options. Health Lifestyles Theory helps explain health inequities by connecting social class (and other group memberships) to health behaviors. It shows that differences in smoking rates, diets, etc. across classes are not random – they reflect broader inequalities in opportunity and socialization. It is insightful because it fills in the pathway between structure and health: explaining how living in poverty can lead to a lifestyle (through stress, coping mechanisms, community norms) that unfortunately predisposes to illness. However, as noted, it can be more descriptive than transformative – it tells us lifestyles differ by class, but unless paired with a critique of why class differences exist (and how to change them), it risks just cataloging disparities. Still, it underscores the point that “choosing a healthy lifestyle” is not equally realistic for everyone given structural constraints – thus aligning with more critical views that blame-the-victim approaches are flawed.
    
    

40. Salutogenesis: Proposed by Aaron Antonovsky, salutogenesis flips the usual question from “what causes disease?” to “what creates health?”. It emphasizes factors that keep people healthy (sense of coherence, resilience, social support, meaningful life, etc.) rather than risk factors for disease. In the context of inequities, salutogenesis offers a positive lens: instead of only seeing what deprived communities lack (risk factors), it also looks for assets and strengths that help some individuals or groups maintain health despite adversity. While salutogenesis itself doesn’t directly analyze power or injustice, it can complement equity work by identifying protective factors that could be bolstered in disadvantaged groups. For example, a salutogenic approach might find that strong community cohesion in an otherwise impoverished area leads to better-than-expected health outcomes; this could inform interventions to build social support networks elsewhere. However, the critique is that focusing too much on “resilience” or protective factors might divert attention from the structural causes of the adversity in the first place. It’s effective in explaining why not everyone exposed to adversity gets ill – because those with more salutogenic resources (like optimism, coping skills, community support) fare better. But relying on salutogenesis alone risks implying communities should just strengthen their coping mechanisms rather than insisting on removing the adversity. In summary, salutogenesis is valuable in highlighting health-promoting factors (which can help reduce outcome disparities by buffering stress), yet by itself it doesn’t tackle why some groups need to be so resilient – which is due to inequitable conditions.
    
    

41. Resilience Theory: Resilience in public health refers to the capacity of individuals or communities to withstand and recover from adversities. Like salutogenesis, it is a strengths-based concept focusing on positive adaptation. Resilience theory acknowledges that some people facing high risks (poverty, trauma, disasters) still manage good health outcomes, and it seeks to understand why. This can explain differences within disadvantaged groups (why some individuals do better than others despite similar hardships) by pointing to factors like supportive relationships, coping skills, or community resources. However, resilience as a guiding concept in inequities can be double-edged. On one hand, it highlights that investing in community and individual resilience (through empowerment, social networks, etc.) can mitigate some health gaps. On the other hand, a heavy emphasis on resilience can inadvertently shift focus away from the causes of the adversities. Critics note that urging oppressed populations to be “more resilient” can imply that the burden of overcoming structural problems falls on the victims, which is unfair and unrealistic. In fact, resilience is sometimes expected of oppressed groups as a way to cope with systemic injustices, which can obscure the imperative to remove those injustices. Therefore, resilience theory explains how some manage to thrive despite inequity, but by itself it doesn’t explain why they had to face such adversity to begin with. It is most useful when paired with efforts to eliminate the need for extraordinary resilience – in other words, building resilience should not replace fighting for systemic change.
    
    

42. Empowerment Theory: Empowerment theory in public health focuses on enabling individuals or communities to gain control over factors affecting their health. It emphasizes increasing people’s capacities, self-efficacy, and group organization to make changes (personal or social). This approach explains inequities by suggesting that a lack of power and control is a fundamental part of why some groups have worse health. For example, low-income communities often have little say in political decisions that impact their environment – empowering those communities (through education, leadership training, community organizing) could lead them to successfully advocate for cleaner streets or better services, thereby improving health. Empowerment is crucial, but some critics (including proponents of Public Health Liberation) argue that if done in a narrow way, it can place too much onus on individuals without challenging the structures that disenfranchise them in the first place. True empowerment in an equity sense should be collective and linked to social justice – not just teaching people to make healthier choices, but also to demand their rights. As an explanatory factor, empowerment theory reminds us that marginalized people often experience disempowerment (helplessness, fatalism) due to their circumstances, which can worsen health outcomes (e.g., feeling unable to change one’s stressors can itself harm mental health, and disempowered patients might not seek care or assert themselves in medical settings). By increasing participation, competence, and control, empowerment strategies address an intermediate layer of inequity – giving people tools to improve their situation – but empowerment alone doesn’t guarantee structural changes unless it’s directed at those goals. In summary, empowerment theory is important because it identifies powerlessness as unhealthy and suggests that building power is part of the cure for health disparities, albeit it must avoid simply making individuals responsible for overcoming systemic barriers by themselves.
    
    

43. Social Capital Theory: Social capital refers to the resources available to individuals and communities through their social networks and relationships, such as trust, reciprocity, information, and support. In public health, higher social capital (especially at community level) has been linked to better health outcomes – for instance, neighborhoods with strong social cohesion often have lower crime and can mobilize for better services, which supports health. Social Capital Theory explains some health inequities by noting that communities differ in social cohesion and support, often correlating with socioeconomic status. Affluent communities may have dense, resource-rich networks that help individuals secure jobs, advice, and help in times of need, whereas impoverished or socially excluded communities may have fractured networks or networks that don’t connect to powerful institutions. This contributes to disparities: e.g., during a heatwave, a high-social-capital community might quickly organize to check on the elderly, whereas in a low-social-capital area isolated seniors might have no one. Social capital can also influence the spread of health information or healthy norms. While useful, one should note that social capital is partly a byproduct of structural conditions – stable jobs, safe gathering places, and equitable policies foster social capital. And sometimes, tight-knit networks can also exclude outsiders (bonding vs. bridging social capital). Nevertheless, as a theory it underscores the health value of social relationships and collective efficacy. It explains why two communities with similar economic profiles might still differ in health outcomes if one has a culture of mutual aid and the other is very fragmented. Building social capital is often seen as an avenue to improve community health and reduce inequities, but like empowerment, it’s a piece of the puzzle (not a substitute for structural fixes).
    
    

44. Cultural Competence Theory: Cultural competence in health refers to the ability of healthcare providers and systems to deliver services that meet the social, cultural, and linguistic needs of patients. The theory behind it is that when care is culturally insensitive or doesn’t account for patients’ backgrounds, it leads to misunderstanding, lower quality care, and disparities. Cultural competence theory helps explain inequities in healthcare outcomes: for example, if doctors are not trained in cultural competence, they may unintentionally alienate or misdiagnose patients from minority cultures (due to language barriers, stereotyping, or lack of understanding of cultural health beliefs), resulting in those patients receiving poorer care. Ensuring culturally competent care (through interpreter services, provider training, diverse workforce, etc.) can reduce disparities by improving patient satisfaction, adherence, and trust. This theory is effective especially in explaining why racial/ethnic minority groups often have worse experiences in the healthcare system – often it’s not just economic barriers, but also cultural barriers and bias. While cultural competence addresses an important facet of equity (quality and accessibility of care), it typically operates within the healthcare system rather than altering broader social determinants. It doesn’t fix poverty or discrimination outside the clinic, but it can mitigate the additional inequity that comes from a “one-size-fits-all” healthcare approach. In summary, cultural competence theory explains that part of health inequity stems from mismatches and biases in cross-cultural encounters in healthcare, and it advocates adapting services to be respectful and effective for all cultures as a remedy.
    
    

45. Health Literacy Theory: Health literacy is the ability of individuals to obtain, understand, and use health information to make appropriate health decisions. Low health literacy is common in populations with less education or where language barriers exist, and it’s associated with poorer health outcomes. This theory explains inequities by highlighting that complex health systems and information can unintentionally exclude or confuse those with lower literacy or limited English, leading to disparities in outcomes. For example, patients with low health literacy may have trouble understanding medication instructions or navigating the healthcare system, resulting in higher hospitalization rates or worse chronic disease management. Health literacy theory calls for simplifying communication (using plain language, visual aids), improving patient education, and making systems easier to navigate. It’s effective in explaining a portion of health inequities: even when healthcare is technically available, it may not be effectively accessible to everyone if communication isn’t tailored. Typically, those with lower socioeconomic status or from marginalized groups have lower average health literacy due to educational inequities, so addressing health literacy is a way to reduce that gap. However, like cultural competence, this theory tackles one dimension of inequity. It doesn’t directly address why groups differ in education to begin with, but it does address the fact that complex information and bureaucracies can widen gaps. By improving health literacy (both by educating patients and by making health information more user-friendly), we can empower disadvantaged groups to better manage their health, thus narrowing some disparities.
    
    

46. Social Cognitive Theory (SCT, Bandura): SCT is a behavioral theory that posits health behaviors are influenced by an interplay of personal factors, behavioral factors, and environmental factors (reciprocal determinism). Key components include observational learning (modeling), self-efficacy (belief in one’s ability to perform a behavior), and outcome expectancies. SCT acknowledges that people do not act in isolation: they learn from their social environment and are influenced by it. In explaining inequities, SCT is a bit better than simplistic behavior models because it does include environment – for instance, someone in a neighborhood where nobody jogs and there are no parks is less likely to exercise (lack models and enabling environment). It can partially explain why certain behaviors (smoking, diet, exercise) cluster in certain communities or social groups. If a disadvantaged community has fewer positive role models for healthy behavior and more daily stressors, SCT would predict lower self-efficacy and more adoption of risky behaviors seen in one’s environment. However, SCT usually treats “environment” in a broad sense and doesn’t specifically tackle power or structural inequities; it might consider family, peers, media as environment but not explicitly policies or historical oppression. It’s useful for designing interventions (like peer education or support groups) that could reduce disparities in behavior by boosting self-efficacy and providing role models in communities that lack them. In summary, Social Cognitive Theory explains health behavior differences by social context and cognitive factors, acknowledging environment more than purely individual models, but it stops short of analyzing how that environment became the way it is (which is where structural theories step in).
    
    

47. Self-Efficacy Theory: Originating from Bandura (and a component of SCT), self-efficacy theory zeroes in on the belief in one’s capability to carry out a behavior or task. High self-efficacy can lead to better health behaviors and perseverance, whereas low self-efficacy can be a barrier to action (“I feel unable to quit smoking, so I won’t try”). In terms of inequities, populations that face systemic barriers often have lowered self-efficacy regarding health management, sometimes due to repeated failures or lack of support. For instance, someone from a low-income background might feel it’s impossible to eat healthy (due to cost/access issues) and thus not attempt it. Self-efficacy theory can explain part of why even when opportunities are present, not everyone benefits equally – those who have been marginalized might not have developed confidence in navigating the health system or making health changes (possibly from experiences of discrimination or lack of success in the past). Interventions to improve self-efficacy (through mastery experiences, coaching, or seeing similar others succeed) can help reduce gaps, empowering individuals to take advantage of health resources. However, if the actual structural barriers remain high, boosting self-efficacy alone has limits. Essentially, this theory speaks to a psychological aspect of inequity: if society continually signals to certain groups that they can’t succeed (or provides them fewer successes), they may internalize those beliefs, affecting their health actions. Addressing self-efficacy is important – for example, programs that specifically build confidence in disease management among historically disadvantaged patients can improve outcomes – but again, it should be coupled with making sure there are real opportunities to succeed. Self-efficacy theory itself doesn’t challenge why resources or past successes were unequal, but it offers insight into how inequality can become self-reinforcing through beliefs.
    
    

48. Behavioral Economics Theory: Behavioral economics brings psychological insights into economic (and health) decision-making, recognizing that humans don’t always act as rational optimizers. It identifies cognitive biases, heuristics, and environmental cues that affect choices – for instance, present bias (short-term rewards trumping long-term benefits) or default effects (we tend to stick with pre-set options). In public health, this theory is used to design “nudges” and incentives that guide people toward healthier behaviors (like automatic enrollment in health programs or small rewards for healthy actions). In explaining inequities, behavioral economics typically looks at how decision environments can be structured for better outcomes. It acknowledges that simply educating people isn’t enough if the context encourages unhealthy choices. For example, placing healthier foods at eye level in stores (“nudge”) can improve diet across the board. However, behavioral economics often treats all individuals as subject to similar biases, without delving into how poverty or stress might amplify or change decision-making. It tends not to explicitly address power structures – it’s more pragmatic and apolitical. That said, one could argue that people in disadvantaged circumstances face different and often more challenging decision environments (scarcity can change cognitive bandwidth). Behavioral economics can contribute to equity by making healthier choices easier or “default”, which might especially help those who have less time, bandwidth, or access to carefully plan their health decisions. It explains some of the gap by pointing out that it’s not just knowledge – environmental cues and mental biases influence behavior, and these might disproportionately impact those under more stress (often the disadvantaged). Yet, critics would note nudges won’t fix big structural issues; they can at best marginally improve behaviors in the short term. In sum, behavioral economics provides useful tactics and explains that human decision-making flaws affect health behaviors in ways that can be tweaked, but it doesn’t tackle root causes of inequity head-on.
    
    

49. Nudge Theory: A subset of behavioral economics popularized by Thaler and Sunstein, nudge theory focuses on how indirect suggestions and changes in the “choice architecture” can influence behavior without restricting choice. Examples include defaulting people into organ donation or designing cafeterias so fruit is more accessible than candy. In terms of inequities, nudges can be used to try to reduce gaps (for instance, reminding low-income patients via text to attend appointments, or simplifying enrollment forms to boost uptake of social benefits). Nudge theory explains behavior by emphasizing that small environmental tweaks can have outsized effects because people often take the path of least resistance. However, a criticism regarding equity is that nudges, while useful, might be a technocratic solution that avoids addressing deeper structural problems. They can improve outcomes modestly, but won’t compensate if, say, a community lacks a clinic entirely. Additionally, some nudges may work better for those already in a position to take advantage (for example, default enrollment in a wellness program helps only if the program exists and is accessible). Nudge theory on its own doesn’t explicitly consider power disparities – it assumes paternalistically that we can help people do better by arranging choices wisely. It can inadvertently sidestep the question of who decides what is a better choice and for whom. That said, in practice nudges have been deployed to help reduce disparities (like automatically enrolling eligible low-income families into health insurance to improve coverage rates). In summary, nudge theory explains that behavior is context-dependent and can be guided subtly, which is a valuable insight. It can be part of equity solutions, but its scope is limited to tweaking individual behavior outcomes rather than altering the structural context of those behaviors.
    
    

50. Diffusion of Innovations Theory: Everett Rogers’ diffusion theory describes how new ideas, behaviors, or technologies spread through communities over time, following adopter categories (innovators, early adopters, majority, laggards). In public health, diffusion theory helps in understanding the uptake of health innovations or practices (like a new vaccine or a smoking cessation method) and designing strategies to speed it up. Regarding inequities, diffusion patterns can sometimes exacerbate disparities: often, more advantaged groups (with better access to information and resources) adopt innovations earlier, while disadvantaged groups adopt later or not at all, at least initially. For instance, when a beneficial new drug comes out, wealthier or better-connected patients might get it first, improving their outcomes, while poorer patients lag behind – a phenomenon sometimes called the “innovation gap.” Over time, diffusion might reach those groups, but meanwhile a disparity widens. Public health can use diffusion theory to mitigate this by ensuring early adopters include diverse communities or by tailoring the communication channels to reach marginalized groups. Diffusion theory explains that social networks and communication channels matter: if marginalized communities are not connected to the networks spreading an innovation, they’ll be late to benefit. So it indirectly explains an element of inequity: unequal social connectivity and information flow. It also highlights characteristics of innovations that affect uptake (like cost, complexity, compatibility with values) – if an innovation is costly or misaligned with the culture of a community, those could become equity issues. While diffusion theory doesn’t explicitly critique social hierarchy, it provides a framework to understand and potentially address the timing aspect of disparities in health improvements. Essentially, it reminds us that who hears about and can act on a health innovation first is often determined by social structure, which is crucial for equity planning.
    
    

51. Health Belief Model (HBM): HBM is a classic individual-level theory positing that health behaviors are driven by personal beliefs about susceptibility, severity, benefits, and barriers, along with cues to action and self-efficacy. It has been widely used to design interventions by changing perceptions (e.g., increasing perceived risk of disease to motivate preventive action). In explaining inequities, HBM is quite limited because it focuses almost entirely on the individual’s mindset and assumes largely rational decision-making based on beliefs. It might explain differences in behavior by noting that different groups have different levels of knowledge or perceived risk (for instance, due to health education disparities), which could be true. But it doesn’t account for the external barriers that often differentiate groups – like whether a “perceived barrier” is actually a real barrier such as cost or lack of access (the model lumps all barriers into an individual’s subjective assessment). HBM has been critiqued for ignoring social context. For example, a low-income person might fully believe that exercise is beneficial (high perceived benefit) and that they’re at risk for heart disease (high perceived susceptibility), but still not exercise because they work two jobs and have no safe park – HBM would frame this as high “barriers,” but that doesn’t capture the structural nature of those barriers. In terms of inequities, if one group has systematically more “barriers” (in the HBM sense), the model doesn’t delve into why – which is where structural analysis is needed. Therefore, HBM by itself is weak in explaining health inequities: it might identify differences in attitudes or knowledge between groups, but it risks implying that fixing those beliefs will fix the behavior gap, which often isn’t sufficient if the underlying conditions aren’t addressed. It remains a useful framework for understanding the psychology of health decisions on an individual level, but for equity, it must be applied with caution and combined with approaches that remove actual barriers.
    
    

52. Information-Motivation-Behavioral Skills Model (IMB): The IMB model is another individual-focused behavior change theory stating that for someone to adopt a health behavior, they must have the information (knowledge about the behavior), the motivation (personal and social incentives to perform it), and the behavioral skills (the tools or strategies to actually do it). It’s been used especially in areas like HIV prevention. In terms of inequities, the IMB model would suggest that disparities in health behaviors could stem from differences in information (e.g., health education quality), motivation (cultural or social support for the behavior), or skills (maybe literacy or self-management skills). This can partially explain some gaps – for instance, if a disadvantaged group has less access to health information or less supportive norms (maybe healthy eating isn’t promoted or feasible in their context) or fewer skills training opportunities, they might lag in adopting certain healthy behaviors. However, similar to HBM, IMB doesn’t explicitly incorporate structural factors beyond how they might indirectly affect those three components. It focuses on individuals’ capabilities and readiness. One strength over HBM is that it highlights skills, which at least introduces the idea of capacity-building (maybe someone needs to learn how to cook healthy on a budget, etc.), and social motivation, which acknowledges social support or pressure. But it still largely puts the onus on the individual to change given the right inputs. IMB can be used to design equitable interventions (for example, ensuring that health information is accessible in multiple languages, or that communities are mobilized to motivate each other, or that free workshops impart needed skills in underserved areas). Yet, it’s not a theory that drives structural changes itself. So, IMB explains inequities in behavior by pointing to deficits or differences in info, motivation, and skills across groups, which often do exist due to broader inequities in education and social environment. It’s a more behaviorally comprehensive model than HBM, but still, if used alone it might “medicalize” the problem (seeing it as lack of knowledge/skills) rather than tackling why those differences exist.
    
    

53. Protection Motivation Theory (PMT): PMT is an individual-level theory that describes how people protect themselves against threats. It involves two appraisal processes: threat appraisal (perceived severity and susceptibility of a threat, minus any “rewards” of the risky behavior) and coping appraisal (perceived efficacy of the protective behavior and self-efficacy, minus perceived costs). The result of these appraisals is protection motivation – the intention to adopt protective behavior. In terms of inequities, PMT could highlight differences in how groups appraise threats and coping. For example, if public health messaging doesn’t reach a marginalized community well, they might underestimate a threat (low perceived severity). Or if the recommended protective behavior seems out-of-reach (say, “work from home during a pandemic” for low-wage essential workers), then coping appraisal will be low (they don’t feel they can do it, or the cost is too high). Thus, one group might be less motivated to follow a guideline not because they don’t care, but because from their standpoint the threat seems less clear or the recommended action seems unfeasible. PMT explains individual decisions under risk, but by itself it doesn’t capture the fact that some populations are put in positions where avoiding threats is much harder (like jobs with exposure, no sick leave, etc. – factors beyond personal appraisal). It assumes rational assessment of threat and coping; in reality, external constraints heavily influence one’s “appraisal.” Like other individual models, PMT can be used to craft communications tailored to different groups (e.g., addressing specific beliefs), which might improve adoption of protective behaviors in underserved groups if done well. But it doesn’t challenge why some groups face bigger threats to begin with or have fewer coping resources. In summary, PMT offers an explanation for why some individuals engage in protective behaviors and others don’t, based on their perceptions; disparities in those perceptions and efficacy beliefs can reflect deeper inequities (like lower trust in authorities, less access to effective tools), but PMT doesn’t inherently address those causes – it’s a tool primarily for influencing behavior through fear appeals and efficacy boosting.
    
    

54. Theory of Planned Behavior/Reasoned Action (TPB/TRA): TRA (and its extension TPB) is a well-known framework stating that behavior is driven by intentions, which in turn are shaped by attitudes (beliefs about outcomes), subjective norms (perceptions of others’ expectations), and (in TPB) perceived behavioral control (similar to self-efficacy). Essentially, if someone has a positive attitude toward a behavior, feels social pressure to do it, and believes they can do it, they’re likely to intend to do it and then do it. When considering inequities, TPB can shed light on some differences in health behaviors: for example, in some communities the social norms might discourage certain healthy behaviors (like exercising might not be common or might even be frowned upon for certain genders), affecting intentions. Or perceived control might be low in a disadvantaged group due to real barriers, reducing intentions even if attitude is positive. However, TPB is often criticized for being too individualistic and assuming access to choices. It doesn’t inherently factor in that some people might have the intention but still fail due to structural barriers (though one could argue that those barriers are reflected in “perceived control” – if barriers are huge, people know they have low control). TPB is largely apolitical; it doesn’t consider how power structures shape norms or attitudes. It might attribute low compliance in some group to “negative attitudes” without digging into why that attitude exists (maybe historical exploitation causing distrust). Thus, TPB can inadvertently lead to blaming the community for “wrong norms” or “wrong beliefs.” It’s useful for designing behavior change campaigns (tailoring messages to attitudes and norms), but on its own it’s inadequate for explaining inequities. It might tell us that a certain group has weaker intentions to, say, get vaccinated because of negative attitudes and low perceived control. But without deeper analysis, we might not address that perhaps their negative attitude comes from genuine mistreatment or lack of representation in healthcare, and their perceived control is low because the vaccine clinic is far away. In sum, TPB explains variance in behavior by psychological factors, which can correlate with group differences, but it doesn’t grapple with the structural reasons behind those psychological differences, making it one of the less effective theories for truly understanding health inequities.
    
    

55. Precaution Adoption Process Model: This stage model outlines how people move from unawareness of a health issue to decision-making and possibly to action and maintenance of precautionary behavior. It has stages like: unaware, unengaged, deciding about acting, deciding not to act or deciding to act, acting, and maintenance. In explaining inequities, this model might be applied to see where different populations are in the adoption of a health-protective behavior. For example, with something like radon testing in homes or adopting COVID-19 vaccination, maybe a higher proportion of one community is “unaware” (due to poor health communication reaching them) whereas another community is mostly in “action” or “maintenance”. The model helps pinpoint stage-specific barriers (maybe one group needs basic awareness, another is aware but hasn’t decided to act due to distrust or cost). It’s useful for designing targeted interventions, but like other behavior-stage models, it abstracts the process away from power dynamics. It assumes individuals progress through stages given the right inputs, but if there are structural barriers, people can’t easily progress even if they want to (the model doesn’t explicitly incorporate external constraints at each stage). It is slightly more nuanced than a yes/no behavior model, which is good because it acknowledges many people are “in between” – which can vary by population. For instance, marginalized communities might linger in the “deciding” stage longer if they have conflicting information or lack resources to act. It doesn’t explain why those conditions exist, but it flags that different strategies are needed at different stages. Overall, the Precaution Adoption Process Model is a fine tool for understanding behavior adoption differences, but by itself it doesn’t address deeper causes of inequity; it will tell us who hasn’t acted and perhaps why in immediate terms (unaware, unsure, etc.), but not the social reason behind that pattern. So it ranks low in explanatory power for inequities except for refining behavior change tactics.
    
    

56. Stages of Change Model (Transtheoretical Model): Similar to the above, this model describes individuals’ readiness to change a behavior in stages: precontemplation, contemplation, preparation, action, maintenance (and sometimes relapse). It’s been widely applied in addiction, smoking cessation, etc. In an inequity context, one might find that disadvantaged populations have different stage distributions (e.g., more in precontemplation for quitting smoking), possibly due to stress, cultural acceptance of the habit, or lack of cessation support. While recognizing that change is a process, the model is still very individual-focused. It doesn’t inherently account for why someone is in precontemplation – maybe the environment around them heavily cues smoking and there are few cues to quit. It can pathologize individuals who are “not ready” without acknowledging that their not-ready status might be influenced by external factors (like more pressing life challenges such as unemployment, which overshadow contemplation of quitting smoking). Stages of Change can indirectly tie to inequity if we consider that interventions haven’t been stage-appropriate in certain groups (like maybe smoking cessation programs are offered assuming everyone is in preparation stage, whereas many in a certain community are in precontemplation because the info hasn’t reached them or alternatives to coping are absent). Nevertheless, like other individual-level behavior models, it doesn’t delve into structural determinants. It is a useful framework for counseling and program design – ensuring we meet people where they are – but not for explaining why certain populations might predominantly be at earlier stages for multiple health behaviors (which likely ties back to structural stressors and less support). Therefore, it’s ranked low for explaining inequities, as it deals with the timing and process of individual change rather than the environment or power structure influencing that change process.
    
    

57. Public Health Realism (PHL-derived): Public Health Realism is a concept emerging from the Public Health Liberation framework. While PHL is idealistic and justice-driven, public health realism injects a pragmatist angle – acknowledging the realpolitik of public health interventions. It likely emphasizes finding practical solutions for equity within existing constraints. For example, it might accept that while we push for big structural changes, we must also make incremental gains using the current system (collaborating with non-ideal partners, working under limited budgets, etc.) to reduce disparities in the short term. In explaining inequities, PHL’s realism would say: we clearly know inequities stem from structural issues; however, realistically, how can we chip away at those within political and economic realities? It might stress evidence-based interventions and “meeting systems where they are” even as we aim to transform them. As a theory on its own, Public Health Realism doesn’t explain why inequities exist (that’s covered by the critical analysis in PHL), but it addresses how to realistically address them. It warns against purely theoretical or overly ambitious plans that ignore constraints. One could interpret it as balancing idealism and feasibility – ensuring that efforts to fix inequities consider power dynamics and resource limitations to be effective. It’s ranked relatively low in explanatory power because it’s more about strategy than cause. It doesn’t provide a new reason for inequity, but rather a lens on how to approach solving it. Some might critique that too much “realism” could slip into accepting the status quo (e.g., incrementalism that fails to challenge root causes). However, when done right, it can make equity efforts more savvy. In summary, Public Health Realism acknowledges that while structural change is the goal, we must navigate the current reality shrewdly – it’s a complement to theories that identify causes, ensuring our strategies are grounded and effective.
    
    

58. Public Health 3.0: Public Health 3.0 is a modern initiative that envisions public health practice as more cross-sectoral, data-driven, and collaborative with community stakeholders. It calls for public health departments to act as “Chief Health Strategists” partnering with other sectors (education, urban planning, business, etc.) to address determinants of health. In principle, this update of public health practice recognizes that health inequities require multisector action. However, critics say PH 3.0 can be overly technocratic, focusing on sophisticated data dashboards and managerial approaches that may not sufficiently empower communities or address power imbalances. For example, a Public Health 3.0 approach might implement a fancy data system to identify disparities and convene a coalition to tackle, say, obesity – but if not attentive, it could become top-down (experts deciding what’s best with community input as a token). Public Health 3.0 tries to explain inequities through better metrics and “Health in All Policies” approaches, highlighting that sectors beyond health care influence inequities. This is good – it mainstreams social determinants thinking. But as a theory of change, if it remains technocratic, it might overlook grassroots voice and structural political advocacy, focusing instead on inter-agency collaboration and innovation. In ranking, PH 3.0 is relatively low because it’s more of a framework for action than an explanatory theory, and its success in addressing inequity depends on how it’s implemented. It’s not inherently anti-oppression, though it certainly can be used for equity if community engagement is real. Essentially, Public Health 3.0 acknowledges complex causes of health disparities (which is a strength), but it may sometimes pursue “modernization” over “transformation”, thus only partially addressing inequities. If not careful, it could strengthen the public health infrastructure without fundamentally changing the power relations that create inequities.
    
    

59. Moral Injury Theory: Moral injury refers to the psychological, spiritual, and social harm that occurs when one perpetrates, witnesses, or fails to prevent actions that deeply violate one’s moral beliefs (often discussed in military contexts or among clinicians facing ethical dilemmas). In public health, one might apply this concept to, say, healthcare providers or public health workers who experience moral injury when, for example, systemic issues force them to deny needed care or witness patients suffer unnecessarily. While moral injury is a serious issue for those individuals, it’s not a theory that explains population health inequities. Rather, it’s a consequence or symptom of working within an unjust system – for instance, a doctor in a low-resource setting may feel moral injury from constantly seeing patients get worse due to inability to pay for treatment. So moral injury theory might highlight how health inequities cause distress even among providers or public officials who are morally burdened by the injustice. It’s important in addressing burnout and advocating for change (providers speaking out that it’s morally injurious to keep people in poverty from getting care). But as for explaining why certain groups have worse health, moral injury doesn’t do that – it instead explains an effect on caregivers within inequitable systems. It ranks very low in direct relevance to explaining health disparities among communities. If anything, one could say pervasive health inequities indicate a moral failing of society, potentially injuring the collective conscience or the frontline workers’ consciences. But moral injury theory doesn’t articulate the causes of inequity – it’s more about the emotional trauma inflicted on individuals by those causes. Thus, in the context of this list, it’s one of the least directly applicable to explaining why inequities exist (though it illuminates a human aspect of enduring or administering an unequal system).
    
    

60. Rational Choice Theory: Rational choice theory assumes that individuals make decisions by rationally weighing costs and benefits to maximize their utility. In health, a simplistic rational choice view would imply people engage in unhealthy or healthy behaviors based on a rational calculus of personal advantage. This theory is highly problematic in explaining health inequities, because it effectively ignores the larger social context and constraints on choice. If taken literally, one might say, “If low-income individuals have worse diets, it’s because they rationally prefer cheap, tasty calories over expensive healthy food given their preferences” – which completely sidesteps issues of food deserts, marketing, stress, or lack of time to cook. Rational choice doesn’t account for imperfect information, unequal access, addiction, habits, cultural factors, or power differences, all of which are crucial in health behavior. By ignoring these, it can dangerously veer into blaming individuals for their poor “choices,” implying that disparities exist because some groups systematically make worse choices due to preference or insufficient will, which is not supported when we consider structural constraints. For example, rational choice might naively predict that everyone will use preventive care if it’s beneficial, yet in reality many don’t because of access issues, mistrust, or cost – not irrationality, but rational response to circumstances. In health economics, while people sometimes apply rational models, there’s widespread recognition that this approach is limited. Among all theories here, rational choice is one of the least effective in explaining inequities: it fails to recognize that not everyone has the same set of options to choose from and that choices are shaped by environment and upbringing. In sum, rational choice theory applied to health can obscure the real causes of inequity by insisting outcomes are simply the aggregate of individual choices, which is a stance that neglects the structural “choice architecture” that often traps people in unhealthy situations.
    
    

61. Biomedical Model: The biomedical model views health purely in terms of biological processes – pathogens, genetics, biochemical imbalances – and focuses on diagnosis and treatment of disease. It has been the dominant paradigm in medicine for over a century. However, when it comes to explaining health inequities, the biomedical model is wholly inadequate. It tends to ignore or downplay social, economic, and environmental factors as outside its scope (“social determinants” were historically not considered “scientific” causes of disease in this model). If one strictly followed a biomedical view, one might attribute differences in health between populations to things like genetic differences or maybe differences in pathogens – which in a few cases can play a role, but overwhelmingly, we know inequities are driven by social conditions. The biomedical model can’t easily account for why life expectancy in a poor neighborhood is lower than a rich one except by pointing to proximal causes (more diabetes, more injuries) without context – essentially treating those like random occurrences or individual problems. It misses the upstream causes. In fact, the biomedical emphasis on molecular and individual disease factors has contributed to a “desocialization” of health science, where researchers ask only biological questions about what are fundamentally social phenomena. This model also generally doesn’t factor in prevention (beyond vaccination and such) – its focus is on curing illness in individuals, not on the distribution of health in society. So it cannot explain, for example, why racial minorities receive poorer quality healthcare or why epidemics disproportionately harm the poor – those lie outside its narrow lens. It’s the lowest ranked here because by ignoring structural inequities, it can inadvertently reinforce them (through neglect). As Farmer and colleagues noted, exclusive focus on molecular disease mechanisms leads to neglect of the social forces that determine who gets sick in the first place. In summary, the biomedical model is great for treating diseases, but it’s the worst framework to explain health inequities, which require understanding the social fabric and systemic issues – dimensions the biomedical model leaves out entirely.
    
    

Conclusion: In public health, theories that foreground structural determinants, power imbalances, and social context (like Fundamental Cause, Critical theories, Intersectionality, etc.) are most powerful for explaining why health inequities arise and persist. They make clear that health gaps are not due to individual or biological failings, but due to unequal allocation of resources, opportunities, and exposures in society. Mid-level theories and models (ecological frameworks, life course, etc.) incorporate some of this thinking and help operationalize solutions, but may not explicitly challenge inequity’s root causes. The lowest-ranked perspectives (purely individual or biomedical models) fail to account for the systematic disadvantage that underlies disparate health outcomes. Ultimately, achieving health equity requires applying the top-ranked frameworks to drive interventions – dismantling structural inequities and building social conditions that allow everyone the opportunity to be healthy. Only by using theories that correctly identify the root causes of health inequity can public health truly address and reduce those inequities.

Sources:

• Braveman, P. (2014). What are Health Disparities and Health Equity? [Definitions and frameworks for health equity].
  
  

• Link, B.G., & Phelan, J. (1995). Social Conditions As Fundamental Causes of Disease. [Origin of Fundamental Cause Theory].
  
  

• Lantz, P. (2021). The Tenets of Critical Race Theory are Essential for Addressing Population Health Disparities. Milbank Quarterly.
  
  

• López, N., & Gadsden, V. (2016). Health Inequities, Social Determinants, and Intersectionality. NAM Perspectives.
  
  

• Williams et al. (2022). Public Health Liberation – An Emerging Transdiscipline to Elucidate and Transform the Public Health Economy. Advances in Clinical Medical Research & Healthcare Delivery.
  
  

• Farmer, P. et al. (2006). Structural Violence and Clinical Medicine. PLoS Medicine.
  
  

• WHO. (2021). Social Determinants of Health – World Health Organization (web).
  
  

• Clinical Public Health. (2023). Internalizing Social Determinants: Ecosocial and Weathering Theories. (excerpts on ecosocial theory challenging biomedical individualism).
  
  

• Suslovic, B. et al. (2023). Resilience is an Adverse Event: A Critical Discussion of Resilience. (critique of resilience focus).
  
  

• [Additional citations embedded throughout text as 【source†lines】].