We identified five key challenges in applying Bourdieu’s concept of cultural capital to public health and epidemiology. These challenges stem from differences in research focus, disciplinary orientations, levels of assessment, underlying principles, and definitions of culture ( Table 1). We then formulated corresponding proposals to address each challenge. The following section describes these challenges and our proposal.

Challenge 1: The Epistemological Divergence Between Bourdieu’s Focus on Power Structures and Public Health’s Focus on Health Promotion.

Bourdieu conceptualized cultural capital as a positive force contributing to the attainment of a higher social status. In contrast, epidemiology, an important tool of public health, frames culture and cultural practices or structures as determinants of health. Following the conceptual causal models of epidemiology, culture and cultural practices can also affect health in a variety of ways and they do not always have positive effects on health under the specific macrosocial conditions (e.g., economic crisis) and subpopulations (e.g., corporate managers in Japan and South Korea). ^{16– 19} For example, dietary customs and the use of pleasurable substances, which can be considered forms of embodied cultural capital within specific social groups, may lead to negative physical health outcomes. Behaviors such as smoking, alcohol consumption, and excessive salt intake are well-documented in the literature as detrimental to health and are widely recognized by the public. ^{20– 23} Cigar smoking, which is favored by individuals in higher social strata, has been associated with an increased risk of oral cancer, acting as a mediator between social class and health. ²⁴ Moreover, historical accounts suggest that in Japan’s Heian period in late 8 ^th to 12 ^th century, members of the aristocracy—who were known for their elegant and refined lifestyles—developed diabetes, likely as a result of their dietary habits. ²⁵ Furthermore, the dose or duration of cultural exposure is also important. For example, when evaluating cultural activities such as sports or musical performance, the outcomes differ between someone who has participated for one year and someone who has been engaged for twenty years. ^{26– 28}

Based on the above, we propose a cultural capital framework for public health and epidemiology that considers its influence on health outcomes ( Figure 1). Specifically, we emphasize the need to examine cultural capital’s role in shaping various causal pathways, including its potential to function as a confounder, mediator, or effect modifier. ²⁹ This framework takes into account both the extent of cultural exposure and the direction of its effects, which can have either positive or negative impacts on health depending on the social context.

Challenge 2: The Need to Consider an Intervention-Oriented Cultural Capital Concept

While Bourdieu’s studies of cultural capital focused primarily on revealing social structures, public health aims to transform and develop equitable environments to promote health and wellbeing. Therefore, when the health effects of cultural capital are identified, it becomes essential to consider how such findings can be translated into appropriate public health interventions. Interventions involving cultural capital require ethical consideration. ¹⁰ However, epidemiology lacks conceptual frameworks for incorporating cultural contexts in the interpretation of research findings and designing interventions. To address this, we propose the concept of contextual validity, which consists of two dimensions ( Table 2).

First, in cases where the target is individual traits associated with embodied cultural capital—such as manners, sensibilities, or dispositions—it is clearly inappropriate to treat these traits in the same way for as distributable resources, such as income. Moreover, the interventions aiming to alter such traits risk generating stigma or undermining latent valid effects of existing culture-oriented practices. ^{30, 31} Even when forms of cultural capital—such as access to museums or education—have demonstrated positive, generalizable, and transferable effects on health outcomes in a particular population, such interventions may still be culturally unacceptable to individuals or communities, or may risk undermining other locally valued cultural resources. ^{10, 32– 34} We refer to these considerations as contextual validity of intervention.

Second, the meaningfulness of a targeted health outcome may vary across cultural contexts, and the interpretation of its effect may differ substantially. ^{10, 35– 37} We refer to these considerations as the contextual validity of outcome. For example, sexual relationship disorders were included in the World Health Organization’s International Classification of Diseases, 10th revision (ICD-10). However, in 2014, the WHO concluded that there was no justification for including these disorders as a category of mental illness, and they were excluded from ICD-11 in 2022. ^{38, 39} As social values and historical contexts change, what was once considered a disease in a given culture may no longer be a valid target for medical intervention.

Conversely, a contextually valid approach to cultural intervention could yield meaningful benefits. Understanding how individuals’ dispositions influence health outcomes or modify the effects of other determinants and interventions can inform the development of effective intervention programs. ^{40, 41} For example, research on the mental health-improving app has shown that individuals’ traits strongly influence how they perceive and respond to different app features: e.g. conscientious individuals may prefer apps that offer relaxation audios, encouragement, and trusted information, while neurotic individuals might be more drawn to apps with relaxation exercises, social support, and clear privacy policies. ⁴² Recent developments in precision public health, particularly tailored interventions that often draw on behavioral economics and social marketing, may be more appropriately understood and contextualized by incorporating the concept of cultural capital. ^{43, 44}

Challenge 3: The Need to Assess Cultural Capital at the Collective Level

Cultural capital studies, including those by Bourdieu, have primarily dealt with cultural capital as an individual-level factor. However, since culture is shared within groups, cultural capital may also function at the collective level. This underscores the need to conceptualize and assess cultural capital at the regional or group level—an approach that aligns with the contextual perspective in social epidemiology, which distinguishes between contextual and compositional effects when analyzing the social determinants of health. The contextual effects refer to the influence of structural characteristics specific to a group that goes beyond the distribution of individual attributes and the sum of individual unit effects (i.e., having emergent properties), while the compositional effects reflect health outcomes explained by individual-level risk factors. ⁴⁵ Multilevel models, introduced by scholars in social epidemiology, aim primarily to distinguish between contextual and compositional effects. ^{45, 46} Thus, we propose the concept of collective cultural capital as a structural determinant of health.

Bourdieu uses the concept of champ to define the field in which the value of cultural capital is determined. This concept plays a central role in his theory. He argued that individuals are embedded in multiple fields rather than a single one. ¹ However, he does not consider the field itself to which individuals belong as a form of capital that directly influences health and well-being. From a social epidemiology perspective, the field can be seen as a collective determinant of health. ^{47– 50} Collective cultural capital is a concept that contributes to the valuation of the field. One caution when implementing the concept of collective cultural capital in quantitative research is to ensure a valid definition of the group. An inappropriate definition can lead to bias, which is recognized in health geography as the modifiable areal unit problem (MAUP). MAUP refers to the phenomenon in which estimates derived from different geographic units of aggregation may differ. ^{51– 53}

Challenge 4: The Need for a Cultural Capital Concept that Encompasses Human Nature beyond the Social Space

A Proposal for Three Subtypes of Cultural Capital: Exchange-Based, Governance-Based, and Existential

Bourdieu’s cultural capital concept presupposes a structure in which individuals are positioned within hierarchical relations—what he terms the social space—through their habitus. ^{1, 2} According to Bourdieu, habitus is a system of dispositions that shapes individuals’ behavior. Through habitus, individuals are categorized by others within the social space and, in turn, categorize others. However, human life also encompasses realms beyond the social space, as cultural practices often give rise to spheres that transcend social hierarchy. For instance, in the Japanese tea ceremony, participants, regardless of social status, share a bowl of tea, emphasizing the value of building fair and simple relationships between individuals that transcend status and position. ⁵⁴ Furthermore, the concept of the social space assumes that individuals’ actions are rooted in selfishness. However, studies across multiple disciplines including neuroscience and cognitive sciences have suggested that humans have inherent altruism, equality seeking, and sharing, and that these characteristics can be manifested in cultural acts. ^{55– 58}

David Graeber, a cultural anthropologist, also criticized the foundational assumption in Bourdieu’s model—that individuals act strategically to maximize personal gain—and argued that neither a purely egoistic nor a purely altruistic view can fully explain human behavior. ⁵⁹ Graeber proposed three moral principles underlying economic relations: hierarchy, exchange, and communism. ⁶⁰ The principle of exchange operates by stripping people of their unique contexts in existence, rendering them measurable and substitutable, e.g., slavery. ⁶⁰ The principle of hierarchy is defined by dominant relationships based on fixed lines of superiority and obligatory giving. The principle of communism is based on non-exchangeability in existence, in contrast to slavery. Communism, in Graeber’s view, is not the Marxist doctrine of ownership of the means of production, but rather an everyday moral principle of mutual aid and unconditional giving. These principles coexist and intermingle in human life. The principles of exchange and hierarchy align with Bourdieu’s concept of the social space, but the principle of communism is not covered by Bourdieu’s framework.

Applying Graeber’s three moral principles to Bourdieu’s theory of cultural capital, we classified cultural capital into three types: exchange-based cultural capital, governance-based cultural capital, and existential cultural capital. The former two are included in Bourdieu’s definition of cultural capital, and we propose existential cultural capital based on Graeber’s communism moral principle. Graeber illustrates the difference between these principles by contrasting examples such as marriage ceremonies and slavery. In certain social rituals, such as marriage ceremonies, the exchange of symbolic objects—e.g., ornaments and cloth—signifies the impossibility of equivalence, affirming that a person cannot be reduced to an equivalent value. In contrast, slavery, which regards people as equivalent to money or other commodities, is a phenomenon likely to happen in commercial economies. He distinguished between commercial economies, and human economies (gift economies), which aim to create, transform, and reconstitute human beings and human relationships. Anthropologist Hitoshi Imamura classified gift-giving into two types: pure gift, in which no return is expected from the recipient, ⁶¹ and reciprocal gift, in which a return is anticipated. Graeber’s principle of communism is based on relationships of gift-giving that do not involve reciprocity, such as immediate repayment or barter, which are characteristic of commercial economies. Like the tea ceremony example, many cultural activities follow the principle of communism often take precedence over those of exchange and hierarchy.

Classifying forms of cultural capital based on these principles resonates with the arguments of the historian Yoshihiko Amino and the philosopher Hannah Arendt. Amino introduced the concept of muen, denoting “a liberated space free from private subjugation” in medieval Japan. This was a domain based on the existential principle, detached from the principles of exchange and governance. He wrote, “Literature, performance, art, religion—culture that moves the soul—is all born within the space of muen and sustained by the people of muen”. ⁶² Similarly, as Hannah Arendt described as follows, the form of cultural capital used as a kind of currency should be classified as exchange-based cultural capital, while culture used for the attainment of social status can be understood as governance-based cultural capital. Cultural value, in contrast, can be understood as grounded in an existential principle—detached from both exchange and governance. Reflecting on the commodification of cultural goods, she identified an overtly utilitarian spirit—one that is unable to think about or evaluate things apart from their function or utility—as philistine.

Culture as the outcome of epidemiologic study: Cultural (or Existential) Well-being

Existential cultural capital can be understood as a determinant of health and wellbeing, but it can also be a component of wellbeing that may be treated as an outcome in epidemiologic study. We suggest calling this cultural well-being or existential well-being when utilizing the concept of existential cultural capital as an outcome in health research. The underlying principle of this form of capital, the unexchangeable nature of being, has historically embodied what is often referred to as humanism. For example, Inuit societies have developed everyday practices that prevent hierarchical relationships from arising through acts of giving, as a means of sustaining their humanity. ⁵⁹ Similarly, traditions such as Buddhist non-discrimination and Christian philanthropy have emphasized domains of giving that transcend exchange and hierarchy. In Eastern philosophies, the idea of unexchangeable being goes beyond notions of individuality or being oneself. It encompasses an awareness found in Zen concepts such as ichi-go ichi-e (a once-in-a-lifetime encounter) and in mindfulness practices that emphasize the irreplaceability of each moment. ⁶⁴ Some countries have legally guaranteed existential cultural capital as a right of citizens. The Constitution of Japan states “All people shall have the right to maintain the minimum standards of wholesome and cultured living”. ⁶⁵ This protection of the right to a cultured living reflects an affirmation of human dignity through cultural expression. ^{65, 66}

This principle of unexchangeable being is inherently pluralistic and particular, and therefore resists standardization or homogenization. It may therefore be regarded as a foundation of dignity, which is a core principle in the ethics of care. ^{67, 68} Care and art are the two social domains where this unexchangeable nature of being, or gift-like function, is most clearly expressed. ^{69, 70} Arendt also noted that the etymological root of the word culture contains the meaning to care, as follows:

She further connected culture to humanism through the Latin term cultura animi, which means cultivation of the soul, and explained: “This humanism is the result of the cultura animi, of an attitude that knows how to take care and preserve and admire the things of the world” (p. 222). ⁶³

In this context, existential cultural capital can serve as a goal of public health in the form of cultural or existential well-being. Culture determines values, and values are concepts of the desirable. They shape our sense of how we ought to live and what is ultimately considered good, forming the existential foundation of well-being. ⁵⁹

Moreover, the unexchangeable existence of cultural well-being arises from a web of countless relationships, which naturally includes connections with non-human beings, inanimate matter, and nature. However, the notion of society in the WHO’s definition of health, as well as the concept of social in social epidemiology, is generally confined to human social relationships, failing to account for non-human entities. Relationships with nature, in contrast, are central to various cultural traditions in Japan, including Shinto, Zen Buddhism, and Daoist philosophy, as well as the animistic worldviews held by indigenous peoples worldwide, all of which deeply inform their conceptions of well-being. ^{71, 72}

The concept of Buen Vivir, meaning the good life in Spanish, which was incorporated into the 2008 revised Ecuadorian constitution, is a translation of Sumak Kawsay in the Indigenous Kichwa language, signifying the fullness of life. While its adoption has been critiqued as a form of cognitive appropriation or mistranslation, the concept points to a mode of existence that emphasizes maintaining harmony with all elements of Pacha—nature and the cosmos. ⁷³

Challenge 5: The Unclear and Inconsistent Definitions of Culture across Research Fields

Bourdieu’s concept of cultural capital refers to “the capital that culture provides individuals to gain social advantage and higher status in society”. ¹ However, definitions of culture remain ambiguous in both Bourdieu’s theory and public health research. In anthropology, traditional dichotomous understandings that separate humans from nature have been widely criticized. Instead, culture is increasingly understood as emerging from interactions and harmony between humans and nature, continuously evolving through the interweaving of multiple generations. ^{74, 75} Through our literature review, we identified, based on this anthropological perspective, the potential multiple dimensions of culture, each containing several subdomains. Specifically, we classified these dimensions into five categories: Relationship, Referents, Principles, Forms, and Levels, and further subcategorized the domains within each as follows, making explicit the diverse meanings and dimensions of culture. This approach enhances the clarity and applicability of the concept of cultural capital in public health research ( Table 3).

Relationship

We conceptualize a type of cultural capital that focuses on the relationship between humans and nature, as a way to evaluate cultural phenomena. We refer to this as nature-related cultural capital, which includes an individual’s sense of connection to nature and perceptions of it. Second, akin to Bourdieu’s focus on individual dispositions and accumulations, we identify internal cultural capital, such as educational background, habits, competencies, and possessions. Third, cultural capital may also reside in human relationships inherently, such as reciprocity, which is considered one form of social capital. ⁷⁶ This type emphasizes the interpersonal dimension of culture and is referred to as interpersonal cultural capital. These categories are not mutually exclusive and in relation to each other, they will help us understand cultural capital better. For example, skills such as numerical ability may be more appropriately understood as internal forms of cultural capital, rather than as being embedded in interpersonal or human–nature relationships. In this sense, cultural capital can be classified according to the domain to which it primarily pertains within the dimension of relationship, which includes three domains: a. Internal; b. Interpersonal; and c. Nature-related.

Referents

Based on these relational foci, we then examine the objects or domains referred to by the term culture. As Monaghan and Just have noted, there are likely more anthropological definitions of culture than the number of anthropologists. ⁷⁷ One of the most frequently cited definitions is by E.B. Tylor, who described culture (or civilization) as “that complex whole which includes knowledge, belief, art, morals, law, custom, and any other capabilities and habits acquired by man as a member of society”. ⁷⁸ On the other hand, 19th-century British poet and critic Matthew Arnold described culture as “the best which has been thought and said”, ⁷⁹ referring to the works of literature, philosophy, classical music, and the fine arts.

Although the concept of culture is inherently polysemous, it can broadly be categorized into two main meanings: culture as the totality of human activity, and cultural activities that express human spiritual refinement. ⁸⁰ In the latter case, the boundary of what counts as cultural activity is socially constructed—defined by social conventions or authorized institutions. ^{81, 82} Based on this distinction, the meaning of culture can be organized along the dimension of referents, which includes two domains: a. Totality of human activity; and b. Cultural activities. Boundaries of cultural activities are determined socially or institutionally. In other words, what is recognized as a cultural resource varies depending on prevailing social norms. Cultural activities can be further classified into three subdomains: b-a. Art, which is often defined in an elusive and negotiated manner among participants who collectively determine its boundaries and quality; b-b. Cultural practices/resources and cultivated knowledge, including traditional performing arts and cultural heritage that may not be classified as art per se but are considered part of cultural activity; and b-c. Leisure, referring to activities that are difficult to classify strictly as art or cultural practices, such as gaming, sports, or gambling.

Principles

Building on the three cultural principles discussed in Section 4, each of the above classifications can be further divided into three domains within the dimension of principles, as follows: a. Exchange-based ; b. Governance-based ; and c. Existential. This dimension, principles, differs from the other dimensions, and is not directly observable through existing data. The development of a dedicated measurement scale is required to assess this dimension.

Forms

The form that culture takes can be understood using Bourdieu’s three forms of cultural capital: embodied, institutionalized, and objectified. ¹ Embodied cultural capital can be further divided, drawing on Bourdieu’s notions of pratique and habitus. Pratique refers to the foundational behavior of everyday life, ⁸³ while habitus is a system of enduring dispositions that orient individual behavior. ¹ Thus, culture can be classified into the following four domains within the dimension of forms: a. Dispositional (values, attitudes, and personality traits that guide behavior, corresponds to the habitus aspect of embodied capital); b. Behavioral (habitual behaviors and cultural participation, corresponds to the pratique aspect of embodied capital); c. Institutionalized (formalized systems and structures, corresponds to institutionalized cultural capital and reflects strong governance-based principle); and d. Objectified (material resources such as artworks, buildings, and ornaments, corresponds to objectified cultural capital).

Levels

As discussed in Section 3, both individual cultural capital and its nested level, collective cultural capital, are assumed. Therefore, within the dimension of levels, culture can be classified into two domains: a. Individual; and b. Collective.

Bourdieu employed the term capital to draw attention to the concealed capital-like properties of culture. ¹ Analogous to how capital in a commodity economy derives its value in relation to the market, Bourdieu argued that the value of cultural capital is determined by the field. He further defined capital as a form of social relation, a social force that exists only within, and derives its effects from, the field in which it is produced and reproduced. ¹ Applying the idea of contextual effects assumed by social epidemiology, we hypothesize that the characteristics of the field additively or synergistically modify the outcomes of the individuals’ capitals belonging to the group.

Based on Bourdieu’s concept and considering that the central aim of public health is to improve (human) health, we define capital in public health as a potential force that contributes to individual or collective health, which determined through its relationship with the field. As Bourdieu’s field theory emphasizes, capital is not an absolute potential, but one whose value is relationally defined. This aligns with Amartya Sen’s idea of capability. ^{84, 85} A key feature of this view for capital is that even the inability to do something, or so-called negativity, can function positively within a particular field/context. In other words, depending on its relationship to the field, capital can function both positively and negatively. For example, assertiveness is valued in the American work environment, its value being determined by that field, but is often discouraged in East Asian culture. As a result, East Asians are disadvantaged in leadership attainment despite equal qualifications. ⁸⁶ This field-dependent conception of capital corresponds to the epidemiological concept of effect modification, in which the field modifies the effect of capital on health outcomes among population subgroups. ^{19, 87} Such a perspective offers a valuable framework for designing culturally grounded interventions in public health.

However, while Bourdieu’s concept of capital is grounded in exchangeable and governance-based principles, based on equivalence or the expectation of return, capital in public health also incorporates the existential principle, grounded in unexchangeable being. This distinction aligns with Graeber’s differentiation between commercial and human economies. In commercial economies, capital is typically measured in monetary terms, reflecting the value of assets and transactions. In contrast, human economies are characterized by forms of gift that do not entail expectations of return; Graeber referred to the circulating money in such contexts as “social currency”. ⁶⁰ Public health operates within both logics, and therefore capital in this field includes aspects not based on equivalence or exchangeability, resembling social currency in gift economies or even human existence itself. Just as one’s life experiences may be seen either as investments convertible into future returns or as irreplaceable sources of meaning and vitality that cannot be exchanged with other values or those of others, we propose that capital in public health includes forms of value derived from unexchangeable forces.

Graeber conceptualizes individuals as nodal beings, emerging from a web of unexchangeable relations rather than reducible to interchangeable entities. ⁶⁰ In public health, this unexchangeable nature of being can be recognized across multiple levels of existence. As previously discussed, existential uniqueness may emerge at the individual level as well as within groups such as families, local communities, nation-states, or categories such as Japanese, New Yorker, or mother. However, once such a group is defined and studied or intervened, the collectivized view and evaluations of the group can create stereotypical and biased understandings. ^{88, 89}

Similar stereotyping and bias can occur when observing individuals: despite the multiplicity of selves that arise in relation to others, individuals are often reduced to a single, fixed self. The meaning of authenticity or being oneself shifts depending on whether it refers to a fixed inner identity or a dynamic, irreplaceable self that emerges between the self and the world. Even when measuring individuality, its meaning may vary across cultures. In Buddhist thought, fixed perceptions are regarded as attachment, while dynamic recognition is expressed as impermanence ( anicca). ⁹⁰ At every level of existence, the dignity that allows us to perceive dynamic singularity, the irreplaceable, is the core of existential cultural capital. However, we should remain cautious of its potential to become a trigger for discrimination or superficial understandings of others once this singularity is fixed. The idea that all beings are connected is fundamentally different from the idea that all beings are the same.

While the use of the concept of existential cultural capital has risks, other types of principle-based cultural capital discussed in this paper, namely exchange-based cultural capital and governance-based cultural capital, also have the potential to either liberate or constrain individuals. Public health interventions should take these ambivalent characteristics into account. Exchange-based principles may strip away uniqueness and erode dignity by subjecting people to calculable equivalence; however, they also provide freedom, such as an equal opportunity for anyone to purchase a bottle of juice with the same 100 yen. Governance-based principles can lead to homogenization and the use of external force to maintain order, by governing bodies, even against one’s will. Yet they also offer the possibility of fairness through redistribution of financial and material resources. Likewise, existential principles, while representing a critical domain for existential well-being, also carry the risk of producing discrimination, prejudice based on stereotypes, or informal hierarchies. Even the act of gift-giving, central to existential cultural capital, can become burdensome when it implicitly entails an obligation to reciprocate. ⁶⁰