Understanding the Upstream Social Determinants of Health

Working Paper

Nazleen Bharmal, Kathryn Pitkin Derose, Melissa Felician, and Margaret M. Weden

RAND Health

WR-1096-RC May 2015 Prepared for the RAND Social Determinants of Health Interest Group

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NazleenȱBharmal,ȱKathrynȱPitkinȱDerose,ȱMelissaȱFelician,ȱandȱMargaretȱWedenȱ

Abstractȱ

Theȱtermȱsocialȱdeterminantsȱofȱhealthȱ(SDOH)ȱisȱoftenȱusedȱtoȱreferȱtoȱanyȱnonmedicalȱfactorsȱ influencingȱhealth,ȱincludingȱhealthȬrelatedȱknowledge,ȱattitudes,ȱbeliefs,ȱorȱbehaviorsȱ(e.g.,ȱ smoking);ȱhowever,ȱSDOHȱalsoȱincludeȱ“upstream”ȱfactors,ȱsuchȱasȱsocialȱdisadvantage,ȱriskȱ exposure,ȱandȱsocialȱinequitiesȱthatȱplayȱaȱfundamentalȱcausalȱroleȱinȱpoorȱhealthȱoutcomes— andȱthusȱrepresentȱimportantȱopportunitiesȱforȱimprovingȱhealthȱandȱreducingȱhealthȱ disparities.ȱThisȱpaperȱdescribesȱandȱcategorizesȱthreeȱtypesȱofȱapproachesȱusedȱtoȱexamineȱ upstreamȱSDOH.ȱSocialȱdisadvantageȱapproachesȱfocusȱonȱtheȱlinkȱbetweenȱhealthȱandȱ neighborhoodȱconditions,ȱworkingȱconditions,ȱeducation,ȱincomeȱandȱwealth,ȱandȱ race/ethnicityȱandȱracism;ȱaȱpotentialȱcausalȱlinkȱisȱtheȱroleȱofȱstressȱrelatedȱtoȱcopingȱwithȱtheseȱ factors.ȱLifeȱcourseȱapproachesȱfocusȱonȱtheȱlinkȱbetweenȱhealthȱandȱcriticalȱorȱsensitiveȱ periodsȱinȱexposureȱtoȱriskȱ(adverseȱchildhoodȱexperiences,ȱintergenerationalȱtransferȱofȱ advantage)ȱasȱwellȱasȱcumulativeȱexposures;ȱtheȱpotentialȱcausalȱlinkȱhereȱmayȱderiveȱfromȱtheȱ effectȱofȱsocialȱstatusȱonȱtheȱregulationȱofȱgenesȱcontrollingȱphysiologicȱfunctionsȱ(e.g.,ȱimmuneȱ functioning).ȱȱHealthȱequityȱapproachesȱconsiderȱtheȱlinkȱbetweenȱhealthȱandȱsocialȱinequitiesȱ stemmingȱfromȱsocioȬdemographicȱfactors,ȱsuchȱasȱclass,ȱimmigrationȱstatus,ȱgender,ȱsexualȱ orientation,ȱandȱdisabilityȱstatus;ȱsocialȱcapitalȱcanȱserveȱtoȱmoderateȱorȱmediateȱtheȱeffectsȱofȱ theseȱfactors.ȱTheȱpaperȱidentifiesȱseveralȱchallengesȱtoȱunderstandingȱupstreamȱSDOH,ȱ includingȱtheȱlongȱandȱcomplexȱcausalȱpathwaysȱlinkingȱtheseȱfactorsȱwithȱhealth,ȱmultipleȱ interveningȱfactors,ȱlimitedȱabilityȱtoȱstudyȱtheseȱfactorsȱusingȱrandomizedȱexperiments,ȱsingleȬ diseaseȬfocusedȱresearchȱfunding,ȱandȱlimitedȱunderstandingȱofȱcommunityȱbuffersȱthatȱcanȱ mitigateȱtheȱeffectsȱofȱSDOH.ȱȱ

Socialȱdeterminantsȱofȱhealthȱ(SDOH)ȱareȱtheȱconditionsȱunderȱwhichȱpeopleȱareȱborn,ȱgrow,ȱ live,ȱwork,ȱandȱageȱ(CommissionȱonȱSocialȱDeterminantsȱofȱHealth,ȱ2008).ȱȱTheȱtermȱisȱoftenȱ usedȱtoȱreferȱbroadlyȱtoȱanyȱnonmedicalȱfactorsȱinfluencingȱhealth,ȱincludingȱhealthȬrelatedȱ knowledge,ȱattitudes,ȱbeliefs,ȱorȱbehaviorsȱ(e.g.,ȱsmoking).ȱȱSDOHȱhaveȱaȱdirectȱimpactȱonȱtheȱ healthȱofȱindividualsȱandȱpopulations;ȱtheyȱalsoȱhelpȱstructureȱlifestyleȱchoicesȱandȱbehaviors,ȱ whichȱinteractȱtoȱproduceȱhealthȱorȱdisease.ȱAtȱtheȱsameȱtime,ȱSDOHȱareȱshapedȱbyȱpublicȱ policyȱandȱthus,ȱinȱtheory,ȱareȱmodifiable.ȱ ȱ AsȱtheȱfieldȱofȱSDOHȱgrows,ȱthereȱisȱincreasingȱemphasisȱonȱunderstandingȱandȱaddressingȱtheȱ fundamentalȱcauses,ȱorȱupstreamȱfactors,ȱofȱpoorȱhealthȱandȱinequities.ȱȱUpstreamȱSDOHȱrefersȱ toȱtheȱmacroȱfactorsȱthatȱcompriseȱsocialȬstructuralȱinfluencesȱonȱhealthȱandȱhealthȱsystems,ȱ governmentȱpolicies,ȱandȱtheȱsocial,ȱphysical,ȱeconomicȱandȱenvironmentalȱfactorsȱthatȱ determineȱhealth.ȱȱȱWhileȱupstreamȱconceptsȱmayȱintuitivelyȱmakeȱsense,ȱtheȱcausalȱpathwaysȱ linkingȱtheseȱdeterminantsȱwithȱhealthȱareȱtypicallyȱlongȱandȱcomplex,ȱandȱoftenȱinvolveȱ multipleȱinterveningȱfactorsȱalongȱtheȱwayȱ(LinkȱandȱPhelan,ȱ1995).ȱȱThisȱcomplexityȱmakesȱitȱaȱ challengeȱtoȱstudy,ȱand,ȱultimately,ȱtoȱaddress,ȱtheȱfundamentalȱupstreamȱcauses.ȱ ȱ ToȱbetterȱunderstandȱtheȱupstreamȱSDOH,ȱweȱprovideȱhereȱaȱsummaryȱofȱtheȱmainȱcategoriesȱ orȱtheoreticalȱapproachesȱforȱunderstandingȱSDOH.ȱȱThisȱdocumentȱisȱnotȱmeantȱtoȱbeȱaȱ comprehensiveȱorȱexhaustiveȱexaminationȱofȱeveryȱSDOHȱframework,ȱbutȱisȱintendedȱtoȱreviewȱ someȱofȱtheȱmoreȱwellȬknownȱframeworksȱforȱaddressingȱSDOHȱinȱresearch,ȱpolicy,ȱandȱ practice.ȱȱȱWeȱemphasizeȱapproachesȱwhereȱthereȱisȱstrongȱevidenceȱofȱaȱlinkȱbetweenȱSDOHȱ andȱhealthȱandȱpromisingȱleverageȱpointsȱforȱimprovingȱindividualȱandȱpopulationȱhealthȱ (socioȬpoliticalȱinterventionsȱtoȱimproveȱpopulationȬlevelȱhealth).ȱȱȱWeȱalsoȱprovideȱexamplesȱatȱ theȱendȱofȱthisȱdocumentȱofȱSDOHȱframeworksȱputȱforthȱbyȱnationalȱandȱinternationalȱhealthȱ institutions.ȱ ȱ TheoreticalȱApproachesȱtoȱSDOHȱȱ ȱȱ Socialȱdisadvantageȱapproachȱandȱhealthȱȱ ȱ Substantialȱresearchȱhasȱlinkedȱeducationalȱattainment,ȱreadingȱlevel,ȱincomeȱ(U.S.),ȱandȱ occupationalȱgradeȱ(asȱusedȱinȱEurope)ȱwithȱhealthȱoutcomesȱthroughoutȱtheȱlifeȱcourse.ȱ Greaterȱsocialȱdisadvantageȱisȱassociatedȱwithȱpoorerȱhealth,ȱandȱthereȱappearsȱtoȱbeȱaȱ“doseȬ response”ȱrelationshipȱorȱstepwise/incrementalȱgradientȱconnectingȱsocialȱdisadvantageȱtoȱ poorerȱhealthȱ(BravemanȱandȱGottlieb,ȱ2014).ȱȱResearchȱisȱneededȱtoȱclarifyȱtheȱunderlyingȱ pathways,ȱandȱhealthȱoutcomesȱcouldȱreflectȱtheȱdirectȱhealthȱbenefitsȱofȱhavingȱmoreȱeconomicȱ resourcesȱ(e.g.,ȱhealthierȱnutrition/foodȱsecurity,ȱhousing,ȱneighborhoodȱconditions),ȱ unmeasuredȱsocioeconomicȱfactors,ȱand/orȱassociatedȱpsychologicalȱorȱbehavioralȱfactorsȱ(e.g.,ȱ perceivedȱcontrol);ȱhowever,ȱreverseȱcausationȱcouldȱbeȱanȱalternativeȱexplanation.ȱȱȱTheȱtheoryȱ ofȱfundamentalȱcausesȱoutlinesȱwhyȱtheȱassociationȱbetweenȱsocioeconomicȱstatusȱandȱhealthȱ disparitiesȱhasȱpersistedȱoverȱtime,ȱandȱpostulatesȱthatȱthoseȱinȱlowȱsocioeconomicȱstatusȱ communitiesȱlackȱresourcesȱtoȱprotectȱand/orȱimproveȱhealthȱ(Phelanȱetȱal.,ȱ2010).ȱSpecifically,ȱ

1 thisȱtheoryȱsuggestsȱthatȱlivingȱconditionsȱandȱsocioeconomicȱstatusȱinfluenceȱmultipleȱdiseasesȱ throughȱmultipleȱriskȱfactorsȱandȱlackȱofȱaccessȱtoȱresourcesȱtoȱreduceȱrisk,ȱandȱthatȱtheȱeffectsȱ areȱreproducedȱoverȱtimeȱ(FlaskerudȱandȱDeLilly,ȱ2012,ȱPhelanȱetȱal.,ȱ2010).ȱ x Neighborhoodȱconditions:ȱȱNeighborhoodsȱcanȱinfluenceȱhealthȱthroughȱphysicalȱ characteristicsȱ(airȱandȱwaterȱquality,ȱexposures,ȱaccessȱtoȱparks),ȱtheȱavailabilityȱandȱ qualityȱofȱneighborhoodȱservicesȱ(transportation,ȱschools,ȱemploymentȱresources,ȱhousing),ȱ andȱsocialȱrelationshipsȱwithinȱaȱgeographicȱcommunityȱ(mutualȱtrustȱamongȱneighborsȱhasȱ beenȱlinkedȱtoȱlowerȱhomicideȱrates)ȱ(WilliamsȱandȱCollins,ȱ2001,ȱBravemanȱetȱal.,ȱ2011,ȱ DiezȱRouxȱandȱMair,ȱ2010).ȱȱȱ x Workingȱconditions:ȱȱTheȱphysicalȱaspectsȱofȱworkȱ(occupationalȱhealthȱandȱsafety)ȱcanȱ influenceȱhealthȱbyȱaffectingȱanȱindividual’sȱriskȱofȱmusculoskeletalȱinjuriesȱandȱdisorders,ȱ sedentariness,ȱandȱobesityȱandȱobesityȬrelatedȱchronicȱconditionsȱ(diabetes,ȱheartȱdisease).ȱ Inȱaddition,ȱtheȱphysicalȱconditionsȱinȱwhichȱworkȱisȱperformedȱ(ventilation,ȱnoiseȱlevel)ȱasȱ wellȱasȱtheȱpsychosocialȱaspectsȱ(highȱdemandȱwithȱlowȱcontrol,ȱperceivedȱimbalanceȱofȱ effortsȱandȱrewards)ȱandȱsocialȱaspectsȱ(mutualȱsupportȱamongȱcoworkers)ȱhaveȱallȱbeenȱ associatedȱwithȱhealth.ȱEmploymentȬrelatedȱearningsȱandȱworkȬrelatedȱbenefitsȱ(medicalȱ insurance,ȱpaidȱleave,ȱscheduleȱflexibility,ȱworkplaceȱwellnessȱprograms,ȱretirementȱ benefits,ȱchildȬȱandȱelderȬcareȱresources)ȱshapeȱtheȱhealthȬrelatedȱdecisionsȱindividualsȱ makeȱforȱthemselvesȱandȱtheirȱfamiliesȱ(Egerterȱetȱal.,ȱ2008).ȱ x Education:ȱȱEducationalȱattainmentȱisȱlinkedȱwithȱhealthȱinȱthreeȱinterrelatedȱways.ȱȱFirst,ȱ educationȱhasȱbeenȱlinkedȱtoȱbetterȱhealthȱthroughȱindividuals’ȱincreasedȱhealthȱknowledgeȱ andȱhealthyȱbehaviors.ȱTheȱmechanismȱisȱlikelyȱexplainedȱinȱpartȱbyȱliteracyȱ(Berkmanȱetȱal.,ȱ 2011,ȱDeWaltȱandȱHink,ȱ2009).ȱSecond,ȱeducationȱshapesȱemploymentȱopportunities,ȱwhichȱ areȱmajorȱdeterminantsȱofȱtheȱeconomicȱresourcesȱthatȱinfluenceȱhealth.ȱThird,ȱeducationȱ canȱinfluenceȱhealthȱthroughȱsocialȱandȱpsychologicalȱfactors,ȱwithȱgreaterȱeducationȱlinkedȱ toȱgreaterȱperceivedȱpersonalȱcontrolȱ(whichȱhasȱbeenȱassociatedȱwithȱbetterȱhealthȱandȱ healthyȱbehaviors),ȱhigherȱsocialȱstanding,ȱandȱincreasedȱsocialȱsupport.ȱTheȱroleȱofȱ educationalȱqualityȱandȱitsȱsupportsȱ–ȱemploymentȱopportunities,ȱprestige,ȱsocialȱnetworksȱ thatȱcomeȱwithȱaȱdegreeȱfromȱanȱeliteȱuniversityȱ–ȱmayȱalsoȱimpactȱhealthȱ(Figureȱ1).ȱ

Figureȱ1:ȱInterrelatedȱpathwaysȱlinkingȱeducationȱtoȱhealthȱ

ȱ ȱȱȱȱȱȱȱSource:ȱBravemanȱP,ȱetȱal.ȱ2011.ȱAnnuȱRevȱPublicȱHealth.ȱ32:381Ȭ98.ȱUsedȱwithȱpermission.ȱ ȱ x Incomeȱandȱwealth:ȱȱEconomicȱresourcesȱreflectȱincomeȱ(monetaryȱearningsȱduringȱaȱspecifiedȱ timeȱperiod)ȱandȱwealthȱ(accumulatedȱmaterialȱassets),ȱbutȱtheȱlatterȱisȱlessȱfrequentlyȱ measuredȱinȱhealthȱstudies.ȱRacial/ethnicȱdifferencesȱinȱincomeȱmarkedlyȱunderestimateȱ differencesȱinȱwealthȱ(Bravemanȱetȱal.,ȱ2005).ȱInȱaddition,ȱincomeȱlossȱdueȱtoȱpoorȱhealthȱ (reverseȱcausation)ȱdoesȱnotȱfullyȱaccountȱforȱtheȱassociationȱbetweenȱincome/wealthȱandȱ healthȱ(Muennig,ȱ2008,ȱKawachiȱetȱal.,ȱ2010).ȱȱSeveralȱresearchersȱhaveȱobservedȱhealthȱ effectsȱofȱincome/wealthȱevenȱafterȱadjustingȱforȱrelevantȱfactors,ȱbutȱtheseȱassociationsȱmayȱ alsoȱreflectȱtheȱeffectsȱofȱeducationalȱattainmentȱandȱquality,ȱchildhoodȱSES,ȱneighborhoodȱ characteristics,ȱworkingȱconditions,ȱandȱsubjectiveȱsocialȱstatus.ȱIncomeȱinequalityȱhasȱoftenȱ beenȱlinkedȱwithȱhealth,ȱpossiblyȱthroughȱerodingȱsocialȱcohesion/solidarityȱ(Wilkinsonȱandȱ Pickett,ȱ2006),ȱalthoughȱaȱcausalȱlinkȱhasȱbeenȱdebatedȱ(KaufmanȱandȱCooper,ȱ1999,ȱ Muntaner,ȱ1999,ȱCooperȱandȱKaufman,ȱ1999).ȱȱȱ x Race/ethnicityȱandȱracism:ȱȱRacismȱrefersȱtoȱdiscriminatoryȱactionsȱandȱattitudes,ȱasȱwellȱasȱtheȱ systemicȱconstraintsȱonȱindividuals’ȱopportunitiesȱandȱresourcesȱbasedȱonȱtheirȱraceȱorȱ ethnicity.ȱȱRacialȱresidentialȱsegregationȱisȱanȱexampleȱofȱinstitutionalȱracismȱthatȱproducesȱ andȱperpetuatesȱsocialȱdisadvantageȱinȱresourceȬchallengedȱneighborhoods,ȱlowȬqualityȱandȱ underȬresourcedȱschools,ȱandȱinadequateȱandȱunsafeȱhousing.ȱRacismȱalsoȱdirectlyȱimpactsȱ

healthȱthroughȱstressȱ(chronicȱstressȱviaȱmicroaggressions1)ȱpathwaysȱ(Szantonȱetȱal.,ȱ2012,ȱ WilliamsȱandȱMohammed,ȱ2009).ȱ x PotentialȱCausalȱLinkȱ–ȱRoleȱofȱStress:ȱȱTheȱimpactȱofȱsocialȱdisadvantageȱonȱhealthȱisȱoftenȱtheȱ resultȱofȱcopingȱwithȱtheȱdailyȱchallengesȱofȱtheseȱinterrelatedȱfactorsȱandȱtheirȱimpactȱonȱ stress.ȱRecentȱevidenceȱimplicatesȱchronicȱstressȱinȱtheȱcausalȱpathwaysȱbyȱlinkingȱmultipleȱ upstreamȱsocialȱdeterminantsȱwithȱhealthȱthroughȱneuroendocrine,ȱinflammatory,ȱimmune,ȱ and/orȱvascularȱmechanisms.ȱȱTheȱaccumulatedȱstrainȱfromȱstressfulȱexperiencesȱmayȱ triggerȱtheȱreleaseȱofȱcortisol,ȱcytokines,ȱandȱotherȱsubstancesȱthatȱcanȱdamageȱtheȱimmuneȱ defenses,ȱvitalȱorgans,ȱandȱphysiologicȱsystems,ȱleadingȱtoȱmoreȬrapidȱonsetȱorȱprogressionȱ ofȱchronicȱillnessȱ(cardiovascularȱdisease,ȱacceleratedȱaging)ȱ(AdlerȱandȱStewart,ȱ2010).ȱȱ Allostaticȱload,ȱi.e.,ȱtheȱbiologicalȱ“wearȬandȬtear”ȱresultingȱfromȱchronicȱexposureȱtoȱsocialȱ andȱenvironmentalȱstressorsȱisȱaȱmulticomponentȱconstructȱofȱtheȱphysiologicȱregulatoryȱ systemȱinȱtheȱperiphery/bodyȱandȱbrainȱ(McEwen,ȱ2002).ȱ ȱȱ Lifeȱcourseȱapproachȱandȱhealthȱ ȱ Aȱlifeȱcourseȱapproachȱtakesȱintoȱaccountȱcriticalȱorȱsensitiveȱperiodsȱinȱexposureȱtoȱriskȱasȱwellȱ asȱdynamicsȱrelatedȱtoȱcumulativeȱexposure.ȱThreeȱmodelsȱofȱlifeȱcourseȱareȱdescribedȱ (Berkman,ȱ2009,ȱElderȱJrȱetȱal.,ȱ2003).ȱInȱtheȱfirstȱmodel,ȱthereȱisȱaȱlatencyȱperiodȱinȱwhichȱearlyȱ childhoodȱorȱevenȱprenatalȱexposuresȱshapeȱsubsequentȱoutcomesȱthatȱmayȱorȱmayȱnotȱbeȱ evidentȱforȱyears.ȱInȱtheȱsecondȱlifeȱcourseȱmodel,ȱexposuresȱthroughoutȱlifeȱhaveȱaȱcumulativeȱ effectȱ(e.g.,ȱtobaccoȱuse).ȱInȱtheȱthirdȱmodel,ȱoftenȱcalledȱsocialȱtrajectory,ȱearlyȱexposuresȱmayȱ createȱopportunitiesȱorȱbarriersȱtoȱcriticalȱexposuresȱinȱlaterȱlife,ȱwhichȱareȱthemselvesȱtheȱ criticalȱexposuresȱlinkedȱtoȱdiseaseȱoutcomesȱ(e.g.,ȱeducationȱimpactsȱjobsȱandȱjobȬrelatedȱ exposures).ȱTwoȱareasȱofȱstrongȱevidenceȱforȱSDOHȱareȱ(1)ȱtheȱimpactȱofȱsocialȱ(dis)advantageȱ overȱtheȱlifeȱcourseȱfromȱearlyȱchildhoodȱexperiencesȱtoȱadultȱhealthȱandȱ(2)ȱtheȱhealthȱofȱfutureȱ generations.ȱUpstreamȱsocialȱdeterminantsȱinfluenceȱhealthȱatȱeachȱlifeȱstageȱ(childhoodȱhealth,ȱ adultȱhealth,ȱfamilyȱhealthȱandȱwellȬbeing),ȱwithȱaccumulatingȱsocialȱ(dis)advantageȱandȱhealthȱ (dis)advantageȱoverȱtime.ȱ ȱ x Adverseȱchildhoodȱexperiencesȱ(ACE):ȱȱAȱstrongȱbodyȱofȱSDOHȱevidenceȱconsidersȱtheȱadverseȱ healthȱeffectsȱofȱearlyȱchildhoodȱexperiencesȱ(associatedȱwithȱfamilyȱsocialȱdisadvantage),ȱ showingȱthatȱearlyȱexperiencesȱaffectȱchildren’sȱcognitive,ȱbehavioral,ȱandȱphysicalȱ development,ȱwhichȱinȱturn,ȱpredictȱcurrentȱandȱfutureȱhealth.ȱBiologicȱchangesȱdueȱtoȱ adverseȱsocioeconomicȱconditionsȱinȱinfancyȱandȱtoddlerȱyearsȱappearȱtoȱbecomeȱ “embedded”ȱinȱchildren’sȱbodies,ȱdeterminingȱtheirȱdevelopmentalȱcapacityȱ(Hertzman,ȱ 1999).ȱLongitudinalȱstudiesȱ(thatȱfollowȱindividualsȱfromȱearlyȱchildhoodȱintoȱyoungȱ adulthood)ȱhaveȱlinkedȱchildhoodȱdevelopmentalȱoutcomesȱwithȱsubsequentȱeducationalȱ attainmentȱ(whichȱisȱassociatedȱwithȱadultȱhealth).ȱHowever,ȱpathwaysȱfromȱACEȱcanȱbeȱ 1ȱMicroaggressionsȱareȱbriefȱandȱcommonplaceȱdailyȱverbal,ȱbehavioral,ȱorȱenvironmentalȱindignities,ȱ whetherȱintentionalȱorȱunintentional,ȱthatȱcommunicateȱhostile,ȱderogatory,ȱorȱnegativeȱracialȱslightsȱandȱ insultsȱtowardȱpeopleȱofȱcolor.ȱ

shapedȱbyȱinterventions.ȱHighȬqualityȱearlyȱchildhoodȱdevelopmentȱinterventionsȱ(e.g.,ȱ First5LAȱinitiatives,ȱHeadȱStart)ȱameliorateȱtheȱeffectsȱofȱsocialȱdisadvantageȱonȱchildren’sȱ developmentȱ(Karolyȱetȱal.,ȱ2006).ȱ ȱ x Theȱintergenerationalȱtransferȱofȱadvantage:ȱȱTwoȱdecadesȱofȱliteratureȱexamineȱhowȱdifferencesȱ inȱsocialȱadvantageȱinfluenceȱhealthȱbothȱoverȱlifetimesȱandȱacrossȱgenerationsȱ(Bravemanȱ andȱBarclay,ȱ2009,ȱBravemanȱetȱal.,ȱ2011).ȱChildrenȱofȱsociallyȱdisadvantagedȱparentsȱareȱ lessȱhealthyȱandȱhaveȱmoreȱlimitedȱeducationalȱopportunities,ȱbothȱofȱwhichȱreduceȱtheirȱ chancesȱforȱgoodȱhealthȱandȱsocialȱadvantageȱinȱadulthood.ȱNewȱresearchȱonȱgeneȬ environmentȱinteractionsȱsuggestsȱthatȱtheȱintergenerationalȱtransmissionȱofȱsocialȱ advantageȱandȱhealthȱmayȱbeȱpartiallyȱexplainedȱbyȱepigeneticȱchangesȱinȱgeneȱexpression2,ȱ whichȱinȱturnȱareȱpassedȱonȱtoȱsubsequentȱgenerationsȱ(KuzawaȱandȱSweet,ȱ2009).ȱ ȱ x PotentialȱCausalȱLinkȱ–ȱEpigenetics:ȱȱAnimalȱstudiesȱsuggestȱthatȱsocialȱstatusȱcanȱaffectȱtheȱ regulationȱofȱgenesȱcontrollingȱphysiologicȱfunctionsȱ(immuneȱfunctioning).ȱEducationalȱ attainment,ȱoccupationalȱclass,ȱworkȱschedules,ȱperceivedȱstress,ȱandȱintimateȱpartnerȱ violenceȱhaveȱbeenȱlinkedȱwithȱchangesȱinȱtelomereȱlength.ȱTelomeresȱareȱDNAȬproteinȱ complexesȱcappingȱtheȱendsȱofȱchromosomes,ȱprotectingȱthemȱagainstȱdamage.ȱTelomereȱ shorteningȱisȱconsideredȱaȱmarkerȱofȱcellularȱagingȱthatȱisȱcontrolledȱbyȱbothȱgeneticȱandȱ epigeneticȱfactors.ȱȱ ȱ Healthȱequityȱapproachȱandȱhealthȱ ȱ Similarȱtoȱraceȱandȱracism,ȱsocialȱinequitiesȱthatȱstemȱfromȱsocioȬdemographicȱ(andȱoftenȱlessȱ modifiable)ȱfactorsȱȬȱsuchȱasȱclass,ȱimmigrationȱstatus,ȱgender,ȱsexualȱorientation,ȱandȱdisabilityȱ statusȱȬȱalsoȱimpactȱhealthȱandȱhealthȱinequities.ȱȱOneȱexampleȱofȱhowȱtoȱconceptualizeȱtheȱ effectȱofȱtheseȱlessȬmodifiableȱfactorsȱonȱhealthȱcomesȱfromȱtheȱBayȱAreaȱRegionalȱHealthȱ InequitiesȱInitiativeȱframework,ȱwhichȱwasȱdevelopedȱbyȱlocalȱpublicȱhealthȱdepartmentsȱinȱSanȱ Franciscoȱ(seeȱfigureȱ6;ȱbetterȱresolutionȱhttp://barhii.org/framework/).ȱȱInȱthisȱframework,ȱthereȱ isȱanȱemphasisȱonȱconsideringȱ“healthȱinȱallȱpolicies,”ȱwhichȱisȱaȱcollaborativeȱapproachȱtoȱ improvingȱtheȱhealthȱofȱallȱpeopleȱbyȱincorporatingȱhealthȱconsiderationsȱintoȱdecisionȬmakingȱ acrossȱsectorsȱandȱpolicyȱareasȱ(Rudolphȱetȱal.,ȱ2013).ȱȱInstitutionalȱpoliciesȱandȱregulationsȱfromȱ corporationsȱandȱbusinesses,ȱgovernmentȱagencies,ȱschools,ȱandȱnonȬprofitȱorganizationsȱcanȱ exacerbateȱorȱimproveȱsocialȱinequitiesȱthroughȱaȱpopulation’sȱlivingȱconditionsȱ(e.g.,ȱphysical,ȱ social,ȱeconomic/work,ȱandȱserviceȱenvironments);ȱinstitutionalȱpoliciesȱincludingȱtaxȱpolicies,ȱ housingȱsegregation,ȱstudentȱquotas,ȱzoningȱpolicies,ȱeducationȱpolicies,ȱimmigrationȱpolicies,ȱ andȱpoliciesȱaboutȱmarriage.ȱȱȱȱOneȱupstreamȱapproachȱtoȱachievingȱhealthȱequityȱisȱtoȱaddressȱ institutionsȱandȱtheirȱinfluenceȱoverȱlivingȱconditions.ȱ ȱ

2ȱEpigeneticsȱrefersȱtoȱtheȱheritableȱchangesȱinȱgeneȱexpressionȱ(turnȱon/turnȱoff)ȱthatȱdoȱnotȱinvolveȱ changesȱtoȱtheȱunderlyingȱDNAȱsequence,ȱi.e.,ȱaȱchangeȱinȱphenotypeȱwithoutȱaȱchangeȱinȱgenotype.ȱ

5 x PotentialȱModerator/Mediatorȱ–ȱSocialȱCapital:ȱȱWhileȱdefinitionsȱvary,ȱsocialȱcapitalȱrefersȱinȱ generalȱtoȱtheȱinstitutions,ȱrelationships,ȱandȱnormsȱthatȱshapeȱtheȱqualityȱandȱquantityȱofȱaȱ society’sȱsocialȱinteractions.ȱTheȱconceptȱofȱsocialȱcapitalȱcanȱbeȱdeconstructedȱintoȱbondingȱ (relationshipsȱbetweenȱfamilyȱmembersȱorȱgoodȱfriends,ȱwhichȱinvolveȱsocialȱsupportȱ and/orȱsharedȱsocialȱidentity),ȱbridgingȱ(relationshipsȱbetweenȱpeopleȱwhoȱareȱmoreȱlooselyȱ connectedȱandȱhaveȱaȱdistinctȱsocialȱidentity,ȱsuchȱasȱmembersȱofȱaȱsportsȱclub),ȱandȱlinkingȱ componentsȱ(relationshipsȱthatȱareȱcharacterizedȱbyȱpowerȱdifferences,ȱsuchȱasȱ employer/employee),ȱasȱwellȱasȱstructuralȱ(participationȱinȱgroupȱactivities)ȱandȱcognitiveȱ componentsȱ(socialȱcohesion,ȱtrust)ȱ(Uphoffȱetȱal.,ȱ2013).ȱThereȱisȱevidenceȱthatȱdemonstratesȱ theȱrelationshipȱbetweenȱdifferentȱmeasuresȱofȱsocialȱcapitalȱandȱhealth,ȱandȱsomeȱevidenceȱ thatȱsocialȱcapitalȱmediatesȱtheȱrelationshipȱbetweenȱincomeȱinequalityȱandȱhealthȱ(Kawachiȱ etȱal.,ȱ1997).ȱOneȱreviewȱfoundȱthatȱbondingȱandȱbridgingȱsocialȱcapital,ȱsuchȱasȱsocialȱ support,ȱsocialȱcohesionȱinȱaȱneighborhood,ȱcloseȱfriends,ȱandȱemotionalȱsupportȱfromȱ familyȱmembers,ȱcanȱbufferȱsomeȱofȱtheȱnegativeȱeffectsȱofȱpovertyȱonȱhealth,ȱandȱmightȱ decreaseȱtheȱvulnerabilityȱofȱpeopleȱwithȱaȱlowerȱpositionȱonȱtheȱsocialȱladder.ȱHowever,ȱ certainȱtypesȱofȱsocialȱcapitalȱmightȱbenefitȱtheȱhealthȱonlyȱofȱthoseȱwhoȱhaveȱsufficientȱ economicȱcapitalȱtoȱaccessȱsufficientȱsocialȱcapitalȱandȱitȱmayȱharmȱtheȱhealthȱofȱthoseȱwhoȱ areȱexcludedȱfromȱparticipationȱinȱtheȱrelevantȱnetworksȱ(e.g.,ȱpoorȱmothersȱareȱlessȱhealthyȱ inȱmoreȬaffluentȱareasȱcomparedȱtoȱlessȬaffluentȱareas)ȱ(Uphoffȱetȱal.,ȱ2013).ȱ ȱ Governanceȱandȱhealthȱ ȱ TheȱWorldȱHealthȱOrganizationȱCommissionȱforȱSocialȱDeterminantsȱofȱHealthȱ(WHOȱCSDH)ȱ broughtȱtogetherȱaȱglobalȱevidenceȱbaseȱofȱwhatȱcouldȱbeȱdoneȱtoȱreduceȱhealthȱinequities,ȱ demonstratingȱthatȱwellȬexecutedȱeconomicȱandȱsocialȱpolicyȱcouldȱimproveȱhealthȱandȱhealthȱ equityȱ(CommissionȱonȱSocialȱDeterminantsȱofȱHealth,ȱ2008,ȱFrielȱandȱMarmot,ȱ2011).ȱȱTheyȱ foundȱthatȱmarkedȱhealthȱinequitiesȱexistȱbetweenȱregions,ȱbetweenȱcountries,ȱandȱwithinȱ countries,ȱandȱthatȱreducingȱtheseȱinequitiesȱrequiresȱattendingȱtoȱtheȱunfairȱdistributionȱofȱ power,ȱmoneyȱandȱresources,ȱandȱtheȱconditionsȱofȱeverydayȱlife.ȱȱOneȱreviewȱexaminedȱtheȱ roleȱofȱgovernanceȱmechanismsȱandȱhealthȱoutcomesȱinȱlowȬȱandȱmiddleȬincomeȱcountriesȱ (Cicconeȱetȱal.,ȱ2014)ȱandȱdiscoveredȱthatȱtheȱassociationȱbetweenȱgovernanceȱmechanismsȱandȱ healthȱvariedȱ(direct,ȱmodified,ȱmoderating,ȱandȱmixed).ȱTheȱqualityȱofȱgovernmentȱ(e.g.,ȱruleȱ ofȱlaw,ȱgovernmentȱeffectiveness,ȱperceivedȱlevelȱofȱcorruption)ȱwasȱpositivelyȱassociatedȱwithȱ healthyȱlifeȱexpectancy,ȱlifeȱexpectancyȱatȱbirth,ȱandȱselfȬreportedȱhealthȱstatus,ȱandȱnegativelyȱ associatedȱwithȱchildȱandȱmaternalȱmortality.ȱPublicȱspendingȱonȱchildȱmortalityȱhadȱaȱstrongerȱ effectȱinȱreducingȱchildȱmortalityȱinȱcountriesȱwithȱlowerȱlevelsȱofȱcorruptionȱandȱhighȱ institutionalȱcapacity.ȱȱHigherȱlevelsȱofȱdemocracyȱreducedȱtheȱimpactȱofȱunfavorableȱeconomicȱ andȱtradeȱpoliciesȱ(detrimentalȱeffectsȱassociatedȱwithȱexports,ȱmultinationalȱcorporations,ȱ internationalȱlendingȱinstitutions)ȱonȱinfantȱmortality.ȱFourȱmechanismsȱbyȱwhichȱgovernanceȱ mightȱinfluenceȱhealthȱinȱtheseȱcountriesȱareȱhealthȱsystemȱdecentralizationȱthatȱenablesȱ responsivenessȱtoȱlocalȱneedsȱandȱvalues;ȱhealthȱpolicymakingȱthatȱalignsȱandȱempowersȱ diverseȱstakeholders;ȱenhancedȱcommunityȱengagement;ȱandȱstrengthenedȱsocialȱcapital.ȱȱȱ ȱ

Inȱgeneral,ȱtheȱempiricalȱliteratureȱlinkingȱgovernanceȱtoȱhealthȱisȱrelativelyȱsparse.ȱBothȱ nationallyȱandȱabroad,ȱpoliciesȱthatȱleadȱtoȱimprovementsȱinȱsocialȱconditions—suchȱasȱhousingȱ mobilityȱpolicies,ȱincomeȱsupplements,ȱearlyȱchildhoodȱacademicȱachievement,ȱandȱtheȱCivilȱ RightsȱMovement/Act—alsoȱaffectȱhealthȱ(Williamsȱetȱal.,ȱ2008).ȱȱ ȱ Challengesȱandȱprioritiesȱ ȱ ThereȱareȱseveralȱchallengesȱtoȱstudyingȱupstreamȱSDOH:ȱ ȱ SDOH’sȱimpactsȱonȱhealthȱoftenȱoccurȱthroughȱcomplexȱrelationshipsȱthatȱplayȱoutȱoverȱ longȱperiodsȱofȱtimeȱandȱinvolveȱmultipleȱintermediateȱoutcomesȱthatȱareȱsubjectȱtoȱ“effectȱ modification”ȱbyȱcharacteristicsȱofȱpeopleȱandȱsettingsȱalongȱtheȱcausalȱchain.ȱForȱexample,ȱ neighborhoodȱsocioeconomicȱdisadvantageȱandȱhigherȱconcentrationȱofȱconvenienceȱstoresȱ haveȱbeenȱlinkedȱtoȱtobaccoȱuseȱ(Chuangȱetȱal.,ȱ2005)ȱandȱlowerȱavailabilityȱofȱfreshȱ produce,ȱwhich—combinedȱȱwithȱconcentratedȱfastȬfoodȱoutletsȱandȱfewȱrecreationalȱ opportunities—canȱȱleadȱtoȱpoorerȱnutritionȱandȱlessȱphysicalȱactivityȱ(Cumminsȱandȱ Macintyre,ȱ2006,ȱGordonȬLarsenȱetȱal.,ȱ2006).ȱHowever,ȱtheȱhealthȱconsequencesȱofȱtheȱ chronicȱdiseasesȱrelatedȱtoȱtheseȱconditionsȱwillȱnotȱappearȱforȱdecades,ȱandȱlongitudinalȱ studiesȱareȱexpensive.ȱȱȱȱ ȱ Theȱcomplexȱmultifactorialȱcausalȱpathwaysȱdoȱnotȱeasilyȱlendȱthemselvesȱtoȱtestingȱwithȱ randomizedȱexperiments,ȱandȱweȱhaveȱlimitedȱabilityȱtoȱmeasureȱupstreamȱdeterminants,ȱ givenȱthatȱcurrentȱmeasuresȱdoȱnotȱfullyȱcaptureȱorȱteaseȱoutȱdistinctȱeffectsȱofȱincome,ȱ wealth,ȱeducation,ȱandȱoccupation.ȱȱWithȱsomeȱnotableȱexceptionsȱ[e.g.,ȱadverseȱchildhoodȱ experiencesȱinȱearlyȱlife;ȱmovingȱtoȱopportunityȱhousingȱexperimentȱ(RobertȱJ.ȱSampson,ȱ 2008);ȱnaturalȱexperimentalȱconditionsȱ(Ludwigȱetȱal.,ȱ2011)],ȱthisȱchallengeȱleadsȱtoȱaȱgapȱinȱ knowledgeȱaboutȱwhen,ȱwhere,ȱandȱhowȱtoȱinterveneȱtoȱaddressȱsocialȱfactorsȱtoȱimproveȱ healthȱandȱreduceȱhealthȱdisparities.ȱȱȱ ȱ Researchȱfundingȱfocusedȱonȱsingleȱdiseasesȱ(asȱopposedȱtoȱfocusingȱonȱcausal/contributoryȱ factorsȱwithȱeffectsȱacrossȱmultipleȱdiseases)ȱpotentiallyȱputsȱSDOHȱresearchȱatȱaȱ disadvantage.ȱȱȱ ȱ Thereȱneedsȱtoȱbeȱaȱrecognitionȱofȱbuffersȱandȱcommunityȱassetsȱthatȱcanȱmitigateȱtheȱeffectȱ ofȱunfavorableȱupstreamȱSDOH,ȱsinceȱnotȱeveryȱindividualȱorȱcommunityȱexposedȱtoȱ adversityȱdevelopsȱdiseaseȱandȱpoorȱhealth.ȱThisȱisȱparticularlyȱimportantȱwhenȱengagingȱinȱ communityȬbasedȱparticipatoryȱresearchȱandȱotherȱstakeholderȬengagedȱresearchȱinitiativesȱ andȱinȱexaminingȱtheȱimpactȱofȱresilience.ȱ ȱ Despiteȱtheseȱchallenges,ȱthereȱareȱseveralȱpriorityȱareasȱforȱSDOHȱresearchȱ(Bravemanȱetȱal.,ȱ 2011).ȱ ȱ

1. Descriptiveȱstudiesȱandȱmonitoringȱforȱchangesȱoverȱtimeȱinȱtheȱdistributionȱofȱkeyȱupstreamȱ socialȱfactorsȱ(income,ȱwealth,ȱeducation)ȱacrossȱgroupsȱdefinedȱbyȱrace/ethnicity,ȱ geography,ȱgender,ȱandȱtheirȱassociationȱwithȱhealthȱoutcomesȱinȱspecificȱpopulationsȱandȱ settings.ȱ

2. Longitudinalȱresearch,ȱincludingȱstudiesȱtoȱbuildȱpublicȬuseȱdatabasesȱwithȱcomprehensiveȱ informationȱonȱbothȱsocialȱfactorsȱandȱhealthȱcollectedȱoverȱmultipleȱgenerationsȱusingȱaȱ rangeȱofȱmethodologicalȱtechniquesȱ–ȱmultipleȱregression,ȱinstrumentalȱvariables,ȱmatchedȱ caseȬcontrolȱdesigns,ȱandȱpropensityȱscoreȱmatchingȱ–ȱtoȱreduceȱbiasȱandȱconfoundingȱdueȱ toȱunmeasuredȱvariables.ȱȱȱ

3. Linkȱknowledgeȱtoȱelucidateȱpathwaysȱandȱassessȱinterventions,ȱorȱbuildȱtheȱknowledgeȱbaseȱ incrementallyȱbyȱlinkingȱaȱseriesȱofȱdistinctȱstudiesȱthatȱexamineȱspecificȱsegmentsȱofȱtheȱ pathwayȱconnectsȱAȱ(upstreamȱdeterminant)ȱtoȱZȱ(ultimateȱhealthȱoutcome).ȱOnceȱtheȱlinksȱ inȱtheȱcausalȱchainȱareȱdocumented,ȱaȱsimilarȱincrementalȱapproachȱcouldȱbeȱappliedȱtoȱ studyȱtheȱeffectivenessȱofȱinterventions,ȱe.g.,ȱtestingȱtheȱeffectsȱofȱanȱupstreamȱinterventionȱ onȱanȱintermediateȱoutcomeȱwithȱestablishedȱlinksȱtoȱhealth.ȱȱȱȱ

4. Testȱmultidimensionalȱinterventionsȱversusȱseekingȱaȱmagicȱbullet.ȱKnowledgeȱofȱpathwaysȱcanȱ pointȱtoȱpromisingȱorȱatȱleastȱplausibleȱapproaches,ȱbutȱgenerallyȱcannotȱindicateȱwhichȱ actionsȱwillȱbeȱeffectiveȱandȱefficientȱunderȱdifferentȱconditions;ȱthatȱknowledgeȱcanȱcomeȱ onlyȱfromȱwellȬdesignedȱinterventionȱresearch,ȱincludingȱbothȱrandomizedȱexperimentsȱ (whenȱpossibleȱandȱappropriate)ȱandȱnonrandomizedȱstudiesȱwithȱrigorousȱattentionȱtoȱ comparabilityȱandȱbias.ȱ

5. Expandȱresearchȱfundingȱbeyondȱsingleȱdiseaseȱand/orȱbiomedicalȱfactorsȱexclusively.ȱȱThisȱwouldȱ alsoȱincludeȱextendingȱtheȱtimeframeȱtoȱevaluateȱprogramsȱorȱpolicies.ȱ

6. Developȱpoliticalȱwillȱtoȱtranslateȱknowledgeȱtoȱaction.ȱThisȱincludesȱdevelopingȱaȱworkforceȱtoȱ understandȱandȱaddressȱSDOH,ȱasȱwellȱasȱprovidingȱevidenceȱtoȱdesignȱsocial/healthȱ policiesȱandȱevaluatingȱsocialȱpoliciesȱimpactȱonȱhealthȱandȱhealthȱequity.ȱ

ȱȱ

APPENDIX:ȱINSTITUTIONALȱFRAMEWORKSȱFORȱUPSTREAMȱSDOHȱ

Inȱthisȱappendix,ȱweȱbrieflyȱdescribeȱandȱillustrateȱinstitutionsȱandȱframeworksȱexaminingȱ upstreamȱSDOH.ȱ ȱ WorldȱHealthȱOrganizationȱ–ȱTheȱWHOȱCommissionȱforȱSocialȱDeterminantsȱofȱHealthȱ(WHOȱ CSDH)ȱconceptualȱframeworkȱ(Figureȱ2)ȱisȱgroundedȱinȱestablishedȱtheoreticalȱtraditionsȱ (material/structuralistȱtheory,ȱpsychoȬsocialȱmodel,ȱsocialȱproductionȱofȱhealthȱmodel,ȱecoȬsocialȱ theory)ȱandȱassumesȱthatȱhealthȱisȱaȱsocialȱphenomenon.ȱTheȱframeworkȱdistinguishesȱ ”structuralȱdeterminants”ȱthatȱincludeȱallȱsocialȱandȱpoliticalȱmechanismsȱ(governance,ȱmacroȬ economicȱpolicy,ȱsocialȱpolicy,ȱpublicȱpolicy,ȱandȱsocialȱandȱculturalȱvalues)ȱthatȱgenerate,ȱ configure,ȱandȱmaintainȱsocioeconomicȱpositionȱ(socialȱclass,ȱgender,ȱorȱethnicity)ȱandȱ ”intermediaryȱdeterminants”ȱincludingȱnotȱonlyȱworkingȱandȱlivingȱconditions,ȱbutȱalsoȱ behavioral,ȱpsychosocial,ȱandȱbiologicalȱfactorsȱandȱtheȱhealthȱcareȱsystemȱperȱse.ȱInteractionsȱ betweenȱstructuralȱandȱintermediaryȱdeterminantsȱthenȱresultȱinȱdifferentiationsȱ(inequities)ȱinȱ healthȱandȱwellȬbeing.ȱȱEvidenceȱtoȱsupportȱtheȱcaseȱforȱaddressingȱSDOHȱisȱdividedȱintoȱ5ȱ actionȱareasȱandȱ9ȱthemes.ȱTheȱactionȱareasȱareȱ(i)ȱadoptȱbetterȱgovernanceȱforȱhealthȱandȱ development;ȱ(ii)ȱpromoteȱparticipationȱinȱpolicymakingȱandȱimplementation;ȱ(iii)ȱfurtherȱ reorientȱtheȱhealthȱsectorȱtowardsȱreducingȱhealthȱinequities;ȱ(iv)ȱstrengthenȱglobalȱgovernanceȱ andȱcollaboration;ȱandȱ(v)ȱmonitorȱprogressȱandȱincreaseȱaccountability.ȱȱTheȱnineȱthemesȱareȱ employmentȱconditions,ȱsocialȱexclusion,ȱpublicȱhealthȱconditions,ȱwomenȱandȱgenderȱequity,ȱ earlyȱchildhoodȱdevelopment,ȱhealthȱsystems,ȱglobalization,ȱmeasurementȱandȱevidence,ȱandȱ urbanization.ȱ(CommissionȱonȱSocialȱDeterminantsȱofȱHealth,ȱ2008).ȱ ȱ Figureȱ2:ȱWHOȱCSDHȱconceptualȱframeworkȱ

ȱ ȱȱȱȱSource:ȱ(SolarȱandȱIrwin,ȱ2010).ȱWorldȱHealthȱOrganization.ȱUsedȱwithȱpermission.ȱ

CentersȱforȱDiseaseȱControlȱandȱPreventionȱȬȱHealthyȱPeopleȱ2020ȱprovidesȱaȱcomprehensiveȱsetȱofȱ 10ȬyearȱnationalȱgoalsȱandȱobjectivesȱforȱimprovingȱtheȱhealthȱofȱallȱAmericansȱthroughȱmoreȱ thanȱ1,200ȱobjectivesȱthatȱspanȱ42ȱdistinctȱhealthȱtopics.ȱTheirȱSDOHȱapproachȱusesȱaȱ“placeȬ based”ȱorganizingȱframeworkȱthatȱreflectsȱ5ȱkeyȱareasȱofȱSDOHȱ(andȱtheirȱunderlyingȱfactors;ȱ seeȱFigureȱ3):ȱeconomicȱstabilityȱ(poverty,ȱemploymentȱstatus,ȱaccessȱtoȱemployment,ȱhousingȱ stability);ȱeducationȱ(highȱschoolȱgraduationȱrates,ȱschoolȱpoliciesȱthatȱsupportȱhealthȱ promotion,ȱschoolȱenvironmentsȱthatȱareȱsafeȱandȱconduciveȱtoȱlearning,ȱenrollmentȱinȱhigherȱ education);ȱsocialȱandȱcommunityȱcontextȱ(familyȱstructure,ȱsocialȱcohesion,ȱperceptionsȱofȱ discriminationȱandȱequity,ȱcivicȱparticipation,ȱincarceration/institutionalization);ȱhealthȱandȱ healthcareȱ(accessȱtoȱhealthȱservices,ȱaccessȱtoȱprimaryȱcare,ȱhealthȱtechnology);ȱȱandȱ neighborhoodȱandȱbuiltȱenvironmentȱ(qualityȱofȱhousing,ȱcrimeȱandȱviolence,ȱenvironmentalȱ conditions,ȱaccessȱtoȱhealthyȱfoods).ȱ ȱ Figureȱ3:ȱSDOHȱareaȱforȱHealthyȱPeopleȱ2020ȱ(HealthyȱPeopleȱ2020,ȱ2014)ȱ

ȱ Source:ȱHealthyȱPeopleȱ2020.ȱ2014.ȱU.S.ȱDepartmentȱofȱHealthȱandȱHumanȱServices.ȱUsedȱwithȱȱȱ permission.ȱ ȱ RobertȱWoodȱJohnsonȱFoundationȱ(RWJF)ȱ–ȱTheȱCommissionȱtoȱBuildȱaȱHealthierȱAmericaȱ frameworkȱshowsȱthatȱhealthȬrelatedȱbehaviorsȱandȱreceiptȱofȱrecommendedȱmedicalȱcareȱ(keyȱ downstreamȱdeterminantsȱofȱanȱindividual’sȱhealth)ȱdoȱnotȱoccurȱinȱaȱvacuum,ȱbutȱareȱshapedȱ byȱupstreamȱdeterminantsȱrelatedȱtoȱtheȱlivingȱandȱworkingȱconditionsȱthatȱinfluenceȱhealthȱ directlyȱ(e.g.,ȱthroughȱtoxicȱexposuresȱorȱstressfulȱexperiences)ȱandȱindirectlyȱ(e.g.,ȱbyȱshapingȱ healthȬrelatedȱchoices).ȱThoseȱconditionsȱareȱshapedȱbyȱtheȱeconomicȱandȱsocialȱopportunitiesȱ andȱresourcesȱofȱindividualsȱandȱpopulationsȱ(Figureȱ4).ȱȱTheȱCommission,ȱconvenedȱinȱ2008,ȱ identifiedȱ8ȱkeyȱsocialȱfactorsȱ(earlyȱlifeȱexperience,ȱeducation,ȱincome,ȱwork,ȱhousing,ȱ community,ȱraceȱandȱethnicity,ȱandȱtheȱeconomy),ȱandȱissuedȱ10ȱrecommendationsȱtoȱimproveȱ theȱnation’sȱhealthȱthatȱspannedȱtheȱareasȱofȱnutrition,ȱphysicalȱactivity,ȱtobacco,ȱearlyȱ

10 childhood,ȱhealthyȱplaces,ȱandȱaccountabilityȱ(RWJFȱCommissionȱtoȱBuildȱaȱHealthierȱAmerica,ȱ 2009).ȱȱInȱaȱrecentȱreȬconvening,ȱtheȱCommissionȱprioritizedȱthreeȱgoals:ȱ1)ȱinvestȱinȱtheȱ foundationsȱofȱlifelongȱphysicalȱandȱmentalȱwellȬbeingȱinȱourȱyoungestȱchildren;ȱ2)ȱcreateȱ communitiesȱthatȱfosterȱhealthȬpromotingȱbehaviors;ȱandȱ3)ȱbroadenȱhealthȱcareȱtoȱpromoteȱ healthȱoutsideȱofȱtheȱmedicalȱsystemȱ(RWJFȱCommissionȱtoȱBuildȱaȱHealthierȱAmerica,ȱ2014).ȱ ȱ Figureȱ4:ȱRWJFȱCommissionȱ(RWJFȱCommissionȱtoȱBuildȱaȱHealthierȱ America,ȱ2009)ȱ

ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱSource:ȱBravemanȱP,ȱetȱal.ȱ2011.ȱAnnuȱRevȱPublicȱHealth.ȱ32:381Ȭ98.ȱUsedȱwithȱpermission.ȱ

ȱ InstituteȱforȱHealthcareȱImprovementȱ(IHI)ȱ–ȱTheȱIHIȱconceptualizesȱsocioeconomicȱfactorsȱandȱ physicalȱenvironmentȱasȱupstreamȱfactorsȱinȱpopulationȱhealthȱthatȱimpactȱindividualȱfactorsȱ (behavioral,ȱphysiologic,ȱresilience).ȱȱIndividualȱfactors,ȱinȱturn,ȱhaveȱanȱeffectȱonȱanȱ individual’sȱpotentialȱforȱdisease/injury,ȱhealthȱstatus,ȱandȱoverallȱqualityȱofȱlifeȱorȱwellȬbeingȱ (StiefelȱandȱNolan,ȱ2012)ȱ(seeȱFigureȱ5).ȱ3ȱȱHealthȱcareȱorganizationsȱ(e.g.,ȱKaiserȱPermanenteȱ HealthcareȱSystem)ȱoftenȱuseȱthisȱframeworkȱinȱpopulationȱhealthȱefforts.ȱȱForȱexample,ȱtraumaȱ hasȱbeenȱlinkedȱtoȱchronicȱdiseases,ȱandȱKaiserȱPermanenteȱhasȱaȱprogramȱtoȱidentifyȱpatientsȱ withȱtraumaȱ(emotionalȱorȱsocial)ȱandȱtoȱengageȱthemȱwithȱcommunityȱresourcesȱtoȱdisruptȱtheȱ cycle.ȱ ȱ

3ItȱisȱnotedȱthatȱtheȱIHIȱModelȱofȱPopulationȱHealthȱisȱbasedȱonȱtheȱmodelȱbyȱEvansȱandȱStoddartȱ(1990).ȱȱ

Figureȱ5:ȱIHIȱFrameworkȱforȱpopulationȱhealthȱdeterminantsȱ

ȱ Source:ȱStiefelȱM,ȱNolanȱK.ȱ2012.ȱIHIȱInnovationȱSeriesȱwhiteȱpaper.ȱCambridge,ȱMassachusetts:ȱ InstituteȱforHealthcareȱImprovement.ȱUsedȱwithȱpermission.ȱȱ ȱ BayȱAreaȱRegionalȱHealthȱInequitiesȱInitiativeȱ(BARHII)ȱ–ȱAȱgroupȱofȱhealthȱdepartmentsȱinȱSanȱ Franciscoȱdevelopedȱaȱconceptualȱframeworkȱthatȱillustratesȱtheȱconnectionȱbetweenȱsocialȱ inequalitiesȱandȱhealth.ȱThisȱframeworkȱhasȱbeenȱusedȱwidelyȱasȱaȱguideȱtoȱhealthȱdepartmentsȱ undertakingȱworkȱtoȱaddressȱhealthȱinequities.ȱTheȱinitiativeȱhasȱbeenȱformallyȱadoptedȱbyȱtheȱ CaliforniaȱDepartmentȱofȱPublicȱHealthȱasȱpartȱofȱtheirȱdecisionmakingȱframework.ȱ

Figureȱ6:ȱBARHIIȱ(BayȱAreaȱRegionalȱHealthȱInequitiesȱInitiativeȱ(BARHII))ȱ

ȱ Source:ȱBARHII.ȱhttp://barhii.org/framework/.ȱUsedȱwithȱpermission.ȱȱ

MacArthurȱResearchȱNetworkȱonȱSESȱandȱHealth:ȱȱThisȱisȱaȱcollaborativeȱgroupȱofȱinvestigatorsȱ whoseȱresearchȱisȱorganizedȱaroundȱanȱintegratedȱconceptualȱmodelȱofȱtheȱenvironmentȱandȱ psychosocialȱpathwaysȱbyȱwhichȱSESȱaltersȱtheȱperformanceȱofȱbiologicalȱsystems,ȱtherebyȱ affectingȱdiseaseȱrisk,ȱdiseaseȱprogression,ȱandȱultimatelyȱmortalityȱ(Adlerȱetȱal.,ȱ2007).ȱTheȱ modelȱaddressesȱseveralȱfactors:ȱ1)ȱthereȱisȱaȱstrong,ȱtwoȬdirectionalȱassociationȱbetweenȱ socioeconomicȱstatusȱandȱhealthȱ(theyȱhaveȱdevelopedȱaȱsubjectiveȱmeasureȱofȱperceivedȱsocialȱ status);ȱ2)ȱwithȱaȱfewȱexceptions,ȱdiseaseȱisȱmoreȱprevalentȱandȱlifeȱexpectancyȱshorter,ȱtheȱ lowerȱanȱindividualȱisȱinȱtheȱSESȱhierarchy;ȱ3)ȱtheȱeffectsȱofȱpovertyȱandȱextremeȱadversityȱ aloneȱdoȱnotȱexplainȱtheȱassociationȱofȱSESȱandȱhealthȱ(theyȱattemptȱtoȱassessȱtheȱgradedȱ relationshipȱbetweenȱSESȱandȱhealth);ȱ4)ȱtheȱassociationȱofȱSESȱandȱhealthȱbeginsȱatȱbirthȱandȱ extendsȱthroughoutȱlife,ȱbutȱtheȱstrengthȱandȱnatureȱofȱtheȱrelationshipȱcanȱvaryȱatȱdifferentȱ stagesȱofȱlifeȱ(theyȱexamineȱtrajectoriesȱofȱSESȱalongȱwithȱtrajectoriesȱofȱrisk);ȱ5)ȱthereȱareȱ multipleȱpathwaysȱbyȱwhichȱSESȱmayȱaffectȱhealth,ȱincludingȱaccessȱandȱqualityȱofȱhealthȱcare,ȱ healthȬrelatedȱbehaviors,ȱindividualȱpsychosocialȱprocesses,ȱandȱphysicalȱandȱsocialȱ environments;ȱ6)ȱsocioeconomicȱstatusȱandȱrace/ethnicityȱinteractȱinȱtheirȱassociationsȱwithȱ health;ȱandȱ7)ȱSESȱgradientsȱcanȱbeȱseenȱinȱpreȬdiseaseȱindicatorsȱsuchȱasȱbloodȱpressure,ȱ cortisolȱpatterns,ȱcentralȱadiposity,ȱandȱcarotidȱatherosclerosisȱ(summaryȱscoresȱofȱtheseȱ

13 indicatorsȱappearȱtoȱbeȱbetterȱpredictorsȱthanȱconventionalȱriskȱfactorsȱofȱcertainȱdiseases,ȱ cognitiveȱandȱphysicalȱdecline,ȱandȱmortality).ȱ ȱ TheȱTaskȱForceȱonȱCommunityȱPreventiveȱServicesȱ(HHS):ȱThisȱconceptualȱmodelȱlinksȱsocialȱ environmentalȱinterventionsȱtoȱhealthȱoutcomes.ȱTheȱpremiseȱisȱthatȱaccessȱtoȱsocietalȱresourcesȱ determinesȱcommunityȱhealthȱoutcomes.ȱSocietalȱresourcesȱtoȱsustainȱhealthȱincludeȱstandardȱ ofȱliving,ȱcultureȱandȱhistory,ȱsocialȱinstitutions,ȱbuiltȱenvironments,ȱpoliticalȱstructures,ȱ economicȱsystems,ȱandȱtechnologyȱ(figureȱ7).ȱTheseȱresourcesȱimpactȱ6ȱintermediateȱoutcomesȱ toȱcommunityȱhealth:ȱneighborhoodȱlivingȱconditions;ȱopportunitiesȱforȱlearningȱandȱ developingȱcapacity;ȱcommunityȱdevelopmentȱandȱemploymentȱopportunities;ȱprevailingȱ communityȱnorms,ȱcustoms,ȱandȱprocesses;ȱsocialȱcohesion,ȱcivicȱengagementȱandȱcollectiveȱ efficacy;ȱandȱhealthȱpromotion,ȱdiseaseȱandȱinjuryȱpreventionȱandȱhealthcare.ȱ ȱ Figureȱ7:ȱTheȱCommunityȱGuide’sȱsocialȱenvironmentȱandȱhealthȱmodelȱ(Andersonȱetȱal.,ȱ2003)ȱ ȱ ȱ

ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱSource:ȱAndersonȱLM,ȱetȱal.ȱ2003.ȱAmȱJȱPrevȱMed.ȱ24(3):25Ȭ31.ȱUsedȱwithȱpermission.ȱȱ ȱ ȱȱ

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