Working Paper Understanding the Upstream Social Determinants of Health 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 RAND working papers are intended to share researchers’ latest findings and to solicit informal peer review. They have been approved for circulation by RAND Health but have not been peer reviewed. Unless otherwise indicated, working papers can be quoted and cited without permission of the author, provided the source is clearly referred to as a working paper. RAND’s publications do not necessarily reflect the opinions of its research clients and sponsors. RAND® is a registered trademark. UnderstandingȱtheȱUpstreamȱSocialȱDeterminantsȱofȱHealthȱ 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 ȱ ȱ ȱ ȱ ȱ ȱ 2 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