Graduate Students Embrace Social-Structural Theories of Health Inequality

A pilot study of a Master of Public Health theory course suggests that graduate students respond enthusiastically when social and structural theories of health are added to a curriculum long dominated by individual-level behavioral models. The study, published in Frontiers in Public Health, surveyed seventeen students enrolled in a required theory course at a public health program specializing in community health education, and found uniformly positive assessments of a syllabus that paired traditional behavioral theories with underrepresented social-structural frameworks such as fundamental cause theory, structural violence, intersectionality, and theories of structural racism.

The motivation for the study lies in a well-documented imbalance in public health pedagogy. Prior analyses of Master of Public Health syllabi found that roughly ninety-three percent of commonly taught theories were behavioral, focusing on individual beliefs, motivation, and self-efficacy rather than on the social hierarchies, power relations, and institutional structures that shape disease distribution. Critics have argued that this “psychological fundamentalism” risks eliding the social-structural drivers of health, leaving practitioners ill-equipped to explain why disease burden falls unevenly across lines of class, race, gender, and citizenship status.

To test whether students would welcome a broader theoretical toolkit, the research team designed a course that split content between behavioral theories drawn from the widely used Glanz, Rimer, and Viswanath textbook and social-structural concepts with no established canon in public health instruction. The behavioral half covered the health belief model, the theory of planned behavior, social cognitive theory, the transtheoretical model, and related frameworks. The social-structural half included the social gradient, structural determinants of health, political economy of health, corporate determinants, life course theory, stigma, and community-based approaches such as popular epidemiology.

Assessment took place during the final class session of a Spring 2019 semester course. Students completed a questionnaire combining Likert scales with open-ended questions, administered after the instructor reviewed course content with the class and left the room to reduce pressure. All seventeen enrolled students participated, yielding a one hundred percent response rate. The researchers analyzed open-ended answers using reflexive thematic analysis, with three authors independently coding responses before reconciling them into shared themes.

The quantitative results were strikingly uniform. Every student rated the theoretical content as either good or very good, with sixty-five percent choosing the highest rating. Equally, all respondents judged the inclusion of social and structural theories to be important or very important, and similar levels of importance were assigned to behavioral theories. When asked which theories should be excluded from future versions of the course, thirteen of seventeen students left the question blank, one wrote that they liked all of them, and only a handful named specific candidates for removal.

The most revealing finding emerged when students ranked theories by relevance to two different goals. Asked which theories mattered most for their future professional work, students split roughly evenly: forty percent of all listed theories were behavioral and sixty percent were social-structural. But when asked which theories were most relevant to addressing health inequalities and achieving health equity, behavioral theories nearly vanished. Of seventy-eight total listings, only three, or four percent, were behavioral, while ninety-six percent were social-structural. Every single top-ranked answer for the health equity question was a social-structural theory, led by the social determinants of health, structural determinants, and the social-ecological model.

Qualitative responses added texture to these numbers. Students described behavioral theories as useful stepping-stones, noting that they provided an accessible introduction before the more complex social-structural material. Several emphasized that the course’s “ecological balance,” spanning multiple levels of the social-ecological model, was itself a strength. On the social-structural side, students highlighted professional relevance and a deeper grasp of the social determinants of health. One student wrote that these theories allow students to think on a deeper level about the issues they see, while another offered the phrase that became the study’s title: they teach us how to look at the world. A third noted their value for thinking upstream, toward the root causes of disease rather than downstream consequences.

The authors frame these findings within the scholarship of teaching and learning and connect them to the broader movement toward structural competency, defined as the trained ability to recognize and respond to disease and its unequal distribution as the outcome of harmful social structures such as policies, institutions, and systems. Structural competency curricula are already being developed for medical education, and the authors argue that incorporating social-structural theory into public health training could play a central role in cultivating this capacity among future practitioners.

The study’s limitations are considerable and acknowledged candidly. Seventeen students in a single course at one program, assessed once after the fact with no baseline or comparison group, cannot support broad generalization. Social desirability bias may have inflated the positive ratings, and students in a community health education specialization may have been predisposed to favor structural perspectives. The instrument itself was piloted with only two students, and an ambiguous instruction about blank responses left the authors unable to distinguish endorsement from oversight.

Even with those caveats, the findings carry practical weight for curriculum designers. The authors suggest that programs worried about overloading a single course might distribute theoretical instruction across required coursework rather than concentrating it, and that future evaluations should measure actual learning and application rather than perceived relevance alone. The absence of a consensus canon for social-structural instruction remains a pressing gap, but this pilot offers evidence that students do not merely tolerate the addition of structural theories to public health education. They see those theories as the essential lens for the field’s central moral project: understanding and dismantling health inequality.

Subject of Research: Student perceptions of behavioral versus social-structural theory content in a graduate public health course

Article Title: “They teach us how to look at the world”: student perceptions of traditional behavioral and underrepresented social-structural theoretical content in a graduate public health course

Article References: Harvey, M., Castle, A., & Mehta, V. (2026). “They teach us how to look at the world”: student perceptions of traditional behavioral and underrepresented social-structural theoretical content in a graduate public health course. Frontiers in Public Health, 14, Article 1893127. https://doi.org/10.3389/fpubh.2026.1893127

Image Credits: AI Generated

DOI: 10.3389/fpubh.2026.1893127

Keywords: public health education, MPH curriculum, behavioral theory, social-structural theory, health inequality, social determinants of health, structural competency, thematic analysis, health equity, theory instruction, They, teach