The Social Determinants of Health: It s Time to Consider the Causes of the Causes

Transcription

1 Nursing in 3D: Diversity, Disprities, nd Socil Determinnts The Socil Determinnts of Helth: It s Time to Consider the Cuses of the Cuses Pul Brvemn, MD, MPH Lur Gottlieb, MD, MPH b ABSTRACT During the pst two decdes, the public helth community s ttention hs been drwn incresingly to the socil determinnts of helth (SDH) the fctors prt from medicl cre tht cn be influenced by socil policies nd shpe helth in powerful wys. We use medicl cre rther thn helth cre to refer to clinicl services, to void potentil confusion between helth nd helth cre. The World Helth Orgniztion s Commission on the Socil Determinnts of Helth hs defined SDH s the conditions in which people re born, grow, live, work nd ge nd the fundmentl drivers of these conditions. The term socil determinnts often evokes fctors such s helth-relted fetures of neighborhoods (e.g., wlkbility, recretionl res, nd ccessibility of helthful foods), which cn influence helth-relted behviors. Evidence hs ccumulted, however, pointing to socioeconomic fctors such s income, welth, nd eduction s the fundmentl cuses of wide rnge of helth outcomes. This rticle brodly reviews some of the knowledge ccumulted to dte tht highlights the importnce of socil nd prticulrly socioeconomic fctors in shping helth, nd plusible pthwys nd biologicl mechnisms tht my explin their effects. We lso discuss chllenges to dvncing this knowledge nd how they might be overcome. University of Cliforni, Sn Frncisco, School of Medicine, Deprtment of Fmily nd Community Medicine, Center on Socil Disprities in Helth, Sn Frncisco, CA b University of Cliforni, Sn Frncisco, School of Medicine, Deprtment of Fmily nd Community Medicine, Center for Helth nd Community, Sn Frncisco, CA Address correspondence to: Pul Brvemn, MD, MPH, University of Cliforni, Sn Frncisco, School of Medicine, Deprtment of Fmily nd Community Medicine, Center on Socil Disprities in Helth, PO Box 0943, 3333 Cliforni St., Ste. 365, Sn Frncisco, CA ; tel ; fx ; e-mil <brvemn@fcm.ucsf.edu> Assocition of Schools nd Progrms of Public Helth 19

2 20 Nursing in 3D: Diversity, Disprities, nd Socil Determinnts A lrge nd compelling body of evidence hs ccumulted, prticulrly during the lst two decdes, tht revels powerful role for socil fctors prt from medicl cre in shping helth cross wide rnge of helth indictors, settings, nd popultions This evidence does not deny tht medicl cre influences helth; rther, it indictes tht medicl cre is not the only influence on helth nd suggests tht the effects of medicl cre my be more limited thn commonly thought, prticulrly in determining who becomes sick or injured in the first plce. 4,6,7,17,18 The reltionships between socil fctors nd helth, however, re not simple, nd there re ctive controversies regrding the strength of the evidence supporting cusl role of some socil fctors. Menwhile, reserchers incresingly re clling into question the ppropriteness of trditionl criteri for ssessing the evidence. 17,19 22 The limits of medicl cre re illustrted by the work of the Scottish physicin, Thoms McKeown, who studied deth records for Englnd nd Wles from the mid-19th century through the erly 1960s. He found tht mortlity from multiple cuses hd fllen precipitously nd stedily decdes before the vilbility of modern medicl-cre modlities such s ntibiotics nd intensive cre units. McKeown ttributed the drmtic increses in life expectncy since the 19th century primrily to improved living conditions, including nutrition, snittion, nd clen wter. 23 While dvnces in medicl cre lso my hve contributed, most uthors believe tht nonmedicl fctors, including conditions within the purview of trditionl public helth, were probbly more importnt; 24 public helth nursing, including its role in dvoccy, my hve plyed n importnt role in improved living stndrds. 27 Another exmple of the limits of medicl cre is the widening of mortlity disprities between socil clsses in the United Kingdom in the decdes following the cretion of the Ntionl Helth Service in 1948, which mde medicl cre universlly ccessible. 28 Using more recent dt, Mrtinson found tht lthough helth overll ws better in the United Kingdom thn in the United Sttes, which lcks universl coverge, disprities in helth by income were similr in the two countries. 29 Lrge inequlities in helth ccording to socil clss hve been documented repetedly cross different Europen countries, gin despite more universl ccess to medicl cre Another often-cited exmple of the limits of medicl cre is the fct tht, lthough spending on medicl cre in the U.S. is fr higher thn in ny other ntion, the U.S. hs consistently rnked t or ner the bottom mong ffluent ntions on key mesures of helth, such s life expectncy nd infnt mortlity; furthermore, the country s reltive rnking hs fllen over time. 33,34 A recent report from the Ntionl Reserch Council nd Institute of Medicine hs documented tht the U.S. helth disdvntge in both morbidity nd mortlity pplies cross most helth indictors nd ll ge groups except those older thn 75 yers of ge; it pplies to ffluent s well s poor Americns, nd to non-ltino white people when exmined seprtely. 35 Other U.S. exmples include the observtion tht, while expnsions of Medicid mternity cre round 1990 resulted in incresed receipt of prentl cre by Africn Americn women, 36,37 rcil disprities in the key birth outcomes of low birthweight nd preterm delivery were not reduced. 38 Although importnt for mternl helth, trditionl clinicl prentl cre generlly hs not been shown to improve outcomes in newborns THE IMPACTS OF SOCIOECONOMIC AND OTHER SOCIAL FACTORS ON MOST HEALTH OUTCOMES A number of studies hve ttempted to ssess the impct of socil fctors on helth. A review by McGinnis et l. estimted tht medicl cre ws responsible for only 10% 15% of preventble mortlity in the U.S.; 45 while Mckenbch s studies suggest tht this percentge my be n underestimte, they ffirm the overwhelming importnce of socil fctors. 25,26 McGinnis nd Foege concluded tht hlf of ll deths in the U.S. involve behviorl cuses; 18 other evidence hs shown tht helth-relted behviors re strongly shped by socil fctors, including income, eduction, nd employment. 46,47 Jeml et l., studying 2001 U.S. deth dt, concluded tht potentilly voidble fctors ssocited with lower eductionl sttus ccount for lmost hlf of ll deths mong working-ge dults in the U.S. 48 Gle nd collegues conducted metnlysis, concluding tht the number of U.S. deths in 2000 ttributble to low eduction, rcil segregtion, nd low socil support ws comprble with the number of deths ttributble to myocrdil infrction, cerebrovsculr disese, nd lung cncer, respectively. 49 The helth impct of socil fctors lso is supported by the strong nd widely observed ssocitions between wide rnge of helth indictors nd mesures of individuls socioeconomic resources or socil position, typiclly income, eductionl ttinment, or rnk in n occuptionl hierrchy. In U.S. s well s Europen dt, this ssocition often follows stepwise grdient pttern, with helth improving incrementlly s socil position rises. This stepwise grdient pttern ws first noted in the United Kingdom. 28,50 Although reserch

3 SDH: Considering the Cuses of the Cuses 21 on the socioeconomic grdient hs been more limited in the U.S., the results of U.S. studies hve mirrored the Europen findings. Figures 1 5 illustrte few exmples using U.S. dt, with socil position reflected by income or by eductionl ttinment. Using ntionl dt, the Ntionl Center for Helth Sttistics Helth, United Sttes, 1998 documented socioeconomic grdients in the mjority of numerous helth indictors mesured cross different life stges. 51 Brvemn nd collegues confirmed those findings using recent U.S. dt. 52 Both Pmuk et l. 51 nd Brvemn et l. 52 found tht socioeconomic grdient ptterns predominted when exmining non-ltino blck nd white groups but were less consistent mong Ltino people. Minkler nd collegues found drmtic socioeconomic grdients in functionl limittions mong people ged yers. This finding is prticulrly remrkble becuse income grdients generlly tend to fltten in old ge. 53 As illustrted in Figure 5, nd in both Pmuk et l. 51 nd Brvemn et l., 52 these socioeconomic grdients in helth hve been observed not only in the U.S. popultion overll, but within different rcil/ethnic groups, demonstrting tht the socioeconomic differences re not explined by underlying rcil/ethnic differences. Indeed, most studies tht hve exmined rcil/ethnic differences in helth fter djusting for socioeconomic fctors hve found tht the rcil/ ethnic differences disppered or were substntilly reduced This does not imply tht the only differences in experiences between rcil/ethnic groups re socioeconomic; for exmple, rcil discrimintion could hrm the helth of individuls of ll socioeconomic levels by cting s pervsive stressor in socil interctions, even in the bsence of nyone s conscious intent to discriminte. 57,58 Furthermore, the blck-white disprity in birth outcomes is lrgest mong highly educted women. 59 Living in society with strong legcy of rcil discrimintion could dmge helth through psychobiologic pthwys, even without overtly discrimintory incidents How do widespred nd persistent socioeconomic grdients in helth dd to evidence tht socil fctors re importnt influences on helth? Strong links between poverty nd helth hve been observed for centuries Observing grded reltionship (s opposed to simple threshold, for instnce t the poverty line) of socioeconomic fctors with mny different helth indictors suggests possible dose-response reltionship, dding to the likelihood tht socioeconomic fctors or fctors closely ssocited with them ply cusl role. Although the effects of bject poverty on helth re rrely disputed, not everyone concurs bout the effects of income nd eduction on helth cross the socioeconomic spectrum. Some hve rgued tht income-helth or eduction-helth reltionships reflect reverse custion (i.e., sickness leding to income loss nd/or lower eductionl chievement). 66 Although ill helth often results in lost income, nd child s poor Figure 1. Life expectncy in the U.S. t ge 25, by eduction nd gender, 2006 Life expectncy t ge 25 (in yers) Source: Deprtment of Helth nd Humn Services (US), Ntionl Center for Helth Sttistics. Helth, United Sttes 2011: with specil feture on socioeconomic sttus nd helth. Life expectncy t ge 25, by sex nd eduction level [cited 2012 Nov 29]. Avilble from: URL: Reported in: Brvemn P, Egerter S. Overcoming obstcles to helth in 2013 nd beyond: report for the Robert Wood Johnson Foundtion Commission to Build Helthier Americ. Princeton (NJ): Robert Wood Johnson Foundtion; 2013.

4 22 Nursing in 3D: Diversity, Disprities, nd Socil Determinnts Figure 2. Infnt mortlity rte in the U.S., by mother s eduction, 2009 Infnt mortlity rte (per 1,000 live births) Source: Mthews TJ, McDormn MF. Infnt mortlity sttistics from the 2009 period linked birth/infnt deth dtset. Ntl Vitl Stt Rep 2013;61:1-28. Also vilble from: URL: [cited 2013 Feb 14]. Reported in: Brvemn P, Egerter S. Overcoming obstcles to helth in 2013 nd beyond: report for the Robert Wood Johnson Foundtion Commission to Build Helthier Americ. Princeton (NJ): Robert Wood Johnson Foundtion; helth could limit eductionl chievement, evidence from longitudinl nd cross-sectionl studies indicte tht these do not ccount for the strong, pervsive reltionships observed. 67 Links between eduction nd helth, furthermore, cnnot be explined by reverse custion becuse once ttined, eductionl ttinment is never reduced. The forementioned evidence reflects ssocitions tht by themselves do not estblish custion. However, the observtionl exmples cited s illustrtions re bcked up by extensive literture employing rnge of techniques (e.g., multiple regression, instrumentl vribles, mtched cse-control designs, nd propensity score mtching) to reduce bis nd confounding due to unmesured vribles. 3,4,7,17,19 This knowledge bse is lso enriched by nturl experiments, 3,36,68,69 qusiexperiments, 70 nd some, lbeit limited, rndomized controlled experiments The overwhelming weight of evidence demonstrtes the powerful effects of socioeconomic nd relted socil fctors on helth, even when definitive knowledge of specific mechnisms nd effective interventions is limited. Accumulted knowledge lso revels, however, tht the effects of ny given socil (including socioeconomic) fctor re often contingent on host of other fctors. 17,75 The third section of this rticle discusses chllenges in studying the effects of socioeconomic fctors tht re reltively upstrem (i.e., closer to underlying or fundmentl cuses) 76 from their helth effects locted downstrem (i.e., ner where helth effects re observed). MULTIPLE MECHANISMS EXPLAIN IMPACTS OF SOCIOECONOMIC AND OTHER SOCIAL FACTORS ON HEALTH Despite countless unnswered questions, knowledge of the pthwys nd biologicl mechnisms connecting socil fctors with helth hs incresed exponentilly during the pst 25 yers. Mounting evidence supports cusl reltionships between mny socil including socioeconomic fctors nd mny helth outcomes, not only through direct reltionships but lso through more complex pthwys often involving biopsychosocil processes. 77 Some spects of socioeconomic fctors re connected to helth vi responses to reltively direct nd rpid-cting exposures. For instnce, led ingestion in substndrd housing contributes to low cognitive function nd stunted physicl development in exposed children; 78,79 pollution nd llergens, lso more common in disdvntged neighborhoods, cn excerbte sthm. 80,81 Socioeconomic nd other socil fctors lso

5 SDH: Considering the Cuses of the Cuses 23 my contribute to worse helth through pthwys tht ply out over reltively short time frmes (e.g., months to few yers) but re somewht more indirect. Fctors ffecting the socil cceptbility of risky helth behviors re cse in point. For instnce, exposure to violence cn increse the likelihood tht young people will perpetrte gun violence; 82 nd the vilbility of lcohol in disdvntged neighborhoods cn influence its use mong young people, ffecting rtes of lcohol-relted trumtic injury. 83 Socioeconomic fctors cn influence sleep, which cn be ffected by work, home, nd neighborhood environments, nd which cn hve short-term helth effects. 84,85 Working conditions cn shpe helth-relted behviors, which, in turn, my impct others; for exmple, workers without sick leve re more likely to go to work when ill, incresing the likelihood of disese spred to coworkers or customers. 86 In ddition to these reltively rpid helth impcts, the effects of socioeconomic nd other socil fctors on helth-relted behviors cn influence disese outcomes tht only mnifest much lter in life. Neighborhood socioeconomic disdvntge nd higher concentrtion of convenience stores hve been linked to tobcco use, even fter djusting for severl individul-level chrcteristics, such s eductionl ttinment nd household income. 87 Lower vilbility of fresh produce, combined with concentrted fst-food outlets nd few recretionl opportunities, cn led to poorer nutrition nd less physicl ctivity. 88,89 The helth consequences of the chronic diseses relted to these conditions generlly will not pper for decdes. The strong nd pervsive reltionships between socioeconomic fctors nd physicl helth outcomes cn reflect even more complex nd long cusl pthwys, which my or my not involve helth behviors s key meditors or modertors. Evns nd Schmberg showed tht the ssocition between durtion of childhood poverty nd dult cognitive function ppers to be explined not only by poverty-relted mteril deficits, but lso prtly by chronic childhood stress. 90 Cutler et l. described widening mortlity disprities by eductionl chievement tht re not explined by behviorl risk fctors such s tobcco use or obesity. 91 Children growing up in socioeconomiclly disdvntged neighborhoods fce greter direct physicl chllenges to helth sttus nd helth-promoting behviors; they lso often experience emotionl nd psychologicl stressors, such s fmily conflict nd instbility rising from chroniclly indequte resources. Adjusting for depression, nxiety, nd other negtive emotionl sttes, however, hs not completely explined the effects of socil fctors on helth. 92 Severl recent reviews hve described the biologicl wer-nd-ter resulting from chronic exposure to socil nd environmentl stressors, commonly Figure 3. U.S. children ged <17 yers with less thn very good helth, by fmily income, Percent of children <17 yers of ge with less thn very good helth Source: Ntionl Survey of Children s Helth. NSCH 2011/2012. Dt query from the Child nd Adolescent Helth Mesurement Inititive, Dt Resource Center for Child nd Adolescent Helth [cited 2013 My 10]. Avilble from: URL: /results?q=2456&r=1&g=458. Reported in: Brvemn P, Egerter S. Overcoming obstcles to helth in 2013 nd beyond: report for the Robert Wood Johnson Foundtion Commission to Build Helthier Americ. Princeton (NJ): Robert Wood Johnson Foundtion; 2013.

6 24 Nursing in 3D: Diversity, Disprities, nd Socil Determinnts Figure 4. Percent of U.S. dults ged >25 yers with ctivity-limiting chronic disese, by fmily income, Percent of dults >25 yers of ge with ctivity-limiting chronic disese Source: Anlyses by Brvemn, Egerter, Cubbin, Pmuk, nd Johnson of dt from the Ntionl Longitudinl Mortlity Study, , first reported in: Brvemn P, Egerter S. Overcoming obstcles to helth: report from the Robert Wood Johnson Foundtion to the Commission to Build Helthier Americ. Princeton (NJ): Robert Wood Johnson Foundtion; referred to s llosttic lod. 99 Allosttic lod is multicomponent construct tht reflects physiologic chnges cross different biologicl regultory systems in response to chronic socil nd environmentl stress. Exmples include observtions tht stress cn induce pro-inflmmtory responses, including production of IL nd C-rective protein, 101 nd tht lower income nd eductionl chievement contribute to higher blood pressure nd unfvorble cholesterol profiles. 102 Physiologicl regultory systems thought to be ffected by socil nd environmentl stressors hve included the hypothlmic-pituitry-drenl xis; sympthetic (utonomic) nervous system; nd immune/inflmmtory, crdiovsculr, nd metbolic systems. 93,95 These systems overlp peripherlly nd in the brin. Another re of rpidly evolving knowledge involves the role of socioeconomic nd other socil fctors in epigenetic processes tht regulte whether genes re expressed or suppressed. 103 Evidence from primte studies suggests tht socil sttus cn ffect the regultion of genes controlling physiologic functions (e.g., immune functioning). 104 In ddition, eductionl ttinment, 105,106 occuptionl clss (e.g., mnul vs. non-mnul work), 107 work schedules, 108 perceived stress, 109,110 nd intimte prtner violence 111 hve ll been linked with chnges in telomere length. 112 Telomeres re DNA-protein complexes cpping the ends of chromosomes, protecting them ginst dmge. Telomere shortening is considered mrker of cellulr ging 113 tht is controlled by both genetic nd epigenetic fctors. Multiple biologicl mechnisms pper to be involved in cusl pthwys from socil fctors to helth outcomes. For exmple, n llosttic lod index combining informtion on multiple biomrkers of helth risk ppers to explin more of the impct of eduction on mortlity thn ny single biologicl indictor lone. 114 Associtions between psychosocil processes nd physiology re further complicted by the effects of timing, such s when nd for how long stressor is experienced in n individul s lifespn. 115,116 Erly-life socioeconomic disdvntge hs been repetedly ssocited with vulnerbility to rnge of dolescent nd dult diseses, 117 independent of dolescent or dult socioeconomic sttus/position Overll, there pper to be both cumultive effects of socioeconomic nd relted socil stressors cross the lifespn, mnifesting in chronic disese in lter dulthood, nd heightened effects of experiences occurring t prticulrly sensitive periods in life (e.g., before ge 5). The physiologic effects of chronic stress is n re of ctive biologicl, psychologicl, nd socil reserch tht seeks to explin the impct of mny socil fctors on helth outcomes. Despite considerble evidence indicting importnt

7 SDH: Considering the Cuses of the Cuses 25 Figure 5. Socioeconomic grdients in poor/fir helth mong dults ged yers within rcil/ethnic groups in the U.S., Percent of dults ged yers in poor/fir helth Source: Anlyses by Cubbin of Behviorl Risk Fctor Surveillnce System survey dt, , reported in: Brvemn P, Egerter S. Overcoming obstcles to helth in 2013 nd beyond: report for the Robert Wood Johnson Foundtion Commission to Build Helthier Americ. Princeton (NJ): Robert Wood Johnson Foundtion; effects of socil fctors on helth, however, not every individul exposed to socioeconomic or other dversity develops disese. Protective socil fctors, such s socil support, self-esteem, nd self-efficcy, my mitigte the deleterious effects of dverse socil conditions. 92,95 Income nd eduction hve not predicted helth s consistently mong Ltino immigrnts in the U.S. s mong other groups; hypothesized explntions hve included protective fctors such s socil support or ttitudes nd norms tht confer resilience. 122,123 Similrly, low income my hve less impct on the helth of individuls in settings in which bsic needs including food, housing, eduction, nd/or medicl cre re met by the stte or fmily. 124 This my be due prtly to ccess to needed goods nd services through routes other thn income, nd lso to n llevition of insecurity bout meeting bsic needs. Income my hve less helth impct where there is less socil stigm ssocited with hving limited economic mens. Genetics lso my ply role in n individul s vulnerbility or resilience to socioeconomic dversity: different individuls biologicl responses to the sme socioenvironmentl trigger cn vry mrkedly ccording to specific genetic polymorphisms. 125 At the sme time, s noted, reserch hs demonstrted tht socioeconomic nd relted socil fctors cn lter whether deleterious (or protective) gene is expressed or suppressed. The grded reltionships repetedly observed (nd illustrted in Figures 1 5) between socioeconomic fctors nd diverse helth outcomes my reflect grdients in resources nd exposures ssocited with socioeconomic fctors. They lso my reflect the impct of subjective socil sttus (i.e., where one perceives oneself s fitting reltive to others in socil hierrchy determined by welth, influence, nd prestige). 126 A growing body of reserch in multiple disciplines including psychology, neurology, immunology, eduction, child development, demogrphy, economics, sociology, nd epidemiology exmines the interply of socioeconomic fctors, psychologicl nd other mediting fctors, nd biology. Evidence hs clerly demonstrted tht reltionships between socioeconomic fctors nd helth re complex, dynmic, nd interctive; tht they my involve multiple mechnisms including epigenetic processes tht lter gene expression; nd tht, t times, they my only mnifest decdes fter exposure. CHALLENGES OF STUDYING HOW SOCIOECONOMIC AND OTHER UPSTREAM SOCIAL FACTORS AFFECT HEALTH While gret dvnces in documenting nd understnding the socil, including socioeconomic, determinnts of helth hve been mde, unnswered questions bout the mechnisms underlying their effects on helth re t lest s plentiful s the nswers we hve to dte. All

8 26 Nursing in 3D: Diversity, Disprities, nd Socil Determinnts rigorous reserch is chllenging, but reserch on the upstrem socil determinnts of helth (SDH) fces prticulr chllenges, bsed in prt on the complexity of the cusl pthwys nd the long time periods during which they often ply out. 17, Some of these brriers re illustrted by the following exmple. Figure 6 presents very simply three generl pthwys through which eduction cn influence mny helth outcomes, reflecting links tht hve been described in the literture. While there is not necessrily consensus bout ech step depicted here, ll re plusible in light of current knowledge, including biologicl knowledge. 132 The first pthwy is widely ccepted: eduction increses knowledge nd skills nd, thus, cn fcilitte helthier behviors. The second pthwy lso is biologiclly plusible. However, while its left-sided brnches (i.e., eduction leding to better, higher-pid work) re not disputed, subsequent links from income to helth through vrious pthwys, such s work-relted benefits, neighborhood opportunities, nd stress, re not typiclly considered s eduction effects. The third pthwy depicts helth effects of eduction through psychobiologicl processes such s control beliefs, subjective socil sttus, nd socil networks, gin bsed on existing literture. 123 Figure 6 illustrtes two of the most dunting chllenges fcing reserch on the socioeconomic nd other upstrem determinnts of helth: 1. Complex, multifctoril cusl pthwys do not lend themselves to testing with rndomized experiments. This digrm is gretly oversimplified: the pthwys pper liner, nd the digrm does not include the multitude of rrows representing how the fctors depicted my interct with ech other nd with other vribles not depicted, such s genetic nd epigenetic fctors. Despite the oversimplifiction, it illustrtes how Figure 6. Pthwys through which eduction cn ffect helth How could eduction ffect helth? Source: Egerter S, Brvemn P, Sdegh-Nobri T, Grossmn-Khn R, Dekker M. Eduction mtters for helth. Exploring the socil determinnts of helth: issue brief no. 6. Princeton (NJ): Robert Wood Johnson Foundtion; 2011.

9 SDH: Considering the Cuses of the Cuses 27 upstrem socioeconomic determinnts such s income, welth, nd eduction could exert their effects over complicted multifctoril pthwys. 133 At ech juncture, there re opportunities for confounding nd interctions. A glnce t this digrm should mke it cler tht this intricte series of cusl reltionships does not lend itself to testing with rndomized controlled trils. Nevertheless, it my be possible to study smll pieces of the cusl web with rndomized experiments, mking incrementl contributions to understnding the overll pthwys. 17 Innovtive pproches to modeling complex, dynmic systems re being developed to ddress these chllenges; however, it is uncertin whether these systems will live up to expecttions There re long time lgs for helth effects to mnifest. The links between socil fctors nd helth often ply out over decdes or genertions; for exmple, chronic disese often tkes multiple decdes to develop. Although we my be ble to use intermedite biomrkers (such s C-rective protein or IL-6) or certin behviors s proxies for helth outcomes, it could be two decdes or more fter the relevnt exposures (e.g., childhood dversity) before even these intermedite mrkers mnifest. Few studies re ble to follow prticipnts for more thn few yers. The long time lg between independent nd dependent vribles represents both scientific nd politicl chllenge. Funders nd politicins wnt results within timefrmes for which they cn tke credit. The Office of Mngement nd Budget generlly requires five-yer-or-less time window for ssessing policy impct. Another brrier to understnding the effects of socil fctors on helth is the difficulty of obtining informtion cross multiple sectors (e.g., s eduction, plnning, housing, lbor, nd helth) nd even cross multiple progrms within given sector. Access to cross-sectorl informtion could improve our understnding 54 nd bility to intervene effectively. However, cross-sectorl collbortions fce multiple brriers, including differing priorities, funding strems, nd timelines cross gencies; overcoming these brriers will require mjor shift in finncil nd politicl incentives. 135 Some institutions, nevertheless, hve begun to encourge these collbortions. For exmple, the U.S. Deprtment of Housing nd Urbn Development hs developed helth council to incorporte helth considertions into federl housing policy. 136 The Robert Wood Johnson Foundtion (RWJF) Commission to Build Helthier Americ hs issued recommendtions for severl nonmedicl cre inititives to improve helth overll while reducing helth disprities, including strong emphsis on high-qulity erly child-cre progrms. 137 The Federl Reserve Bnk hs recently collborted with RWJF to convene series of ntionl nd regionl forums to discuss intersections between community development nd helth improvement CONCLUSIONS Despite chllenges, controversies, nd unnswered questions, the tremendous dvnces in knowledge tht hve occurred in the pst 25 yers leve little room for doubt tht socil fctors re powerful determinnts of helth. The consistency nd reproducibility of strong ssocitions between socil (including socioeconomic) fctors nd multitude of helth outcomes in diverse settings nd popultions hve been well documented, nd the biologicl plusibility of the influence of socil fctors on helth hs been estblished. It is not surprising tht exceptionl exmples of helth indictors, settings, nd subgroups in which helth does not necessrily improve with greter socil dvntge cn be found. There my be thresholds bove which higher degree of given socil fctor (e.g., income) no longer yields better helth. Exceptions would lso be expected s the effects of ny given fctor re contingent upon the presence of myrid other fctors socil, economic, psychologicl, environmentl, genetic, nd epigenetic. Considering the long, complex cusl pthwys leding from socil fctors prticulrly upstrem ones such s income nd eduction to helth, with opportunities for countless interctions t ech step, it is indeed remrkble tht there re so few exceptions to the generl rule. The reltive importnce of socil vs. genetic fctors is often debted. The emerging wreness of geneenvironment interctions, however, hs drsticlly ltered nture-vs.-nurture debtes. Socil nd genetic cuses of disese cn no longer be seen s mutully exclusive. We now know tht dverse genetic endowment is not necessrily unlterble, tht bd (or good ) gene my be expressed only in the presence of triggers in the socil or physicl environment, nd tht these environments potentilly cn be modified by socil policies. Despite gps in current knowledge, the cse for needing to ddress upstrem socioeconomic fctors is strong, nd enough is known to inform interventions, which must be rigorously evluted. 17 Given tht SDH including socioeconomic conditions such s income, welth, nd eduction re by definition

10 28 Nursing in 3D: Diversity, Disprities, nd Socil Determinnts outside the relm of stndrd medicl cre, wht is the relevnce to public helth prctitioners nd medicl cre providers? Mny public helth prctitioners hve little experience in sectors outside public helth-cre delivery. Medicl cre providers, including nurses, physicins, nd others, undergo intensive trining in medicine, not in socil work, nd we believe in the power of medicl cre to hel, llevite suffering, nd sve lives. Nevertheless, the knowledge indicting crucil role for socioeconomic nd relted socil fctors in shping helth hs become so compelling tht it cnnot be ignored insofr s public helth nd helth-cre personnel re committed to helth. Current knowledge suggests wys to collborte with others to improve helth outcomes for socilly disdvntged popultions. 138 At minimum, pprecition of some of the socil fctors tht influence helthrelted behviors nd helth sttus itself cn help clinicl providers develop more effective tretment plns. 139 Clinicl nd public helth prctitioners cn strengthen routine procedures to ssess nd respond to socil needs through referrls nd/or on-site socil nd legl services Public helth workers nd clinicins lso cn develop helth-promotion strtegies tht rech beyond individul clinicl nd socil services to communities, to influence living nd working conditions tht re generlly the strongest determinnts of whether people re helthy or become sick in the first plce. 143 They cn prticipte in or promote reserch dding to the understnding of the mechnisms by which socil fctors influence helth, nd test which strtegies pper most effective nd efficient. Finlly, clinicins nd public helth prctitioners cn be key resources for locl, stte, nd ntionl policy mkers on the crucil issue of helth equity for ll Americns, including those fcing the gretest socil obstcles. The uthors thnk Kitlin Aren nd Rbi Aslm for their outstnding reserch ssistnce. REFERENCES 1. Mrmot M, Bell R. Fir society, helthy lives. Public Helth 2012;126 Suppl 1:S Rose G. The strtegy of preventive medicine. New York: Oxford University Press; World Helth Orgniztion, Commission on Socil Determinnts of Helth. Closing the gp in genertion: helth equity through ction on the socil determinnts of helth. CSDH finl report. Genev: WHO; Brvemn P, Egerter S, Willims DR. The socil determinnts of helth: coming of ge. Annu Rev Public Helth 2011;32: Amick BC 3rd, Levine S, Trlov AR, Wlsh DC, editors. Society nd helth. New York: Oxford University Press; Adler NE, Mrmot M, McEwen BS, Stewrt J, editors. Socioeconomic sttus nd helth in industril ntions: socil, psychologicl, nd biologicl pthwys. New York: New York Acdemy of Sciences; Adler NE, Stewrt J, editors. The biology of disdvntge: socioeconomic sttus nd helth. New York: John Wiley & Sons; Ntionl Reserch Council, Committee on Evlution of Children s Helth. Children s helth, the ntion s welth: ssessing nd improving child helth. Wshington: Ntionl Acdemies Press; Kpln GA, Shem SJ, Leite CM. Socioeconomic determinnts of psychologicl well-being: the role of income, income chnge, nd income sources during the course of 29 yers. Ann Epidemiol 2008;18: Koch CG, Li L, Kpln GA, Wchtermn J, Shishehbor MH, Sbik J, et l. Socioeconomic position, not rce, is linked to deth fter crdic surgery. Circ Crdiovsc Qul Outcomes 2010;3: Lynch JW, Everson SA, Kpln GA, Slonen R, Slonen JT. Does low socioeconomic sttus potentite the effects of heightened crdiovsculr responses to stress on the progression of crotid therosclerosis? Am J Public Helth 1998;88: Lynch JW, Kpln GA, Shem SJ. Cumultive impct of sustined economic hrdship on physicl, cognitive, psychologicl, nd socil functioning. N Engl J Med 1997;337: Mrmot MG, Shipley MJ, Rose G. Inequlities in deth specific explntions of generl pttern? Lncet 1984;1: Mrmot MG, Smith GD, Stnsfeld S, Ptel C, North F, Hed J, et l. Helth inequlities mong British civil servnts: the Whitehll II study. Lncet 1991;337: Rose G, Mrmot MG. Socil clss nd coronry hert disese. Br Hert J 1981;45: Shonkoff JP, Phillips DA, editors; Committee on Integrting the Science of Erly Childhood Development, Ntionl Reserch Council nd Institute of Medicine. From neurons to neighborhoods: the science of erly childhood development. Wshington: Ntionl Acdemy Press; Brvemn PA, Egerter SA, Woolf SH, Mrks JS. When do we know enough to recommend ction on the socil determinnts of helth? Am J Prev Med 2011;40(1 Suppl 1):S McGinnis JM, Foege WH. Actul cuses of deth in the United Sttes. JAMA 1993;270: Kelly MP, Morgn A, Bonnefoy J, Butt J, Bergmn V. The socil determinnts of helth: developing n evidence bse for politicl ction. Finl report of the Mesurement nd Evidence Knowledge Network to the World Helth Orgniztion Commission on the Socil Determinnts of Helth. Genev: WHO; Anderson LM, Brownson RC, Fullilove MT, Teutsch SM, Novick LF, Fielding J, et l. Evidence-bsed public helth policy nd prctice: promises nd limits. Am J Prev Med 2005;28(5 Suppl): Fielding JE, Briss PA. Promoting evidence-bsed public helth policy: cn we hve better evidence nd more ction? Helth Aff (Millwood) 2006;25: Glsgow RE, Emmons KM. How cn we increse trnsltion of reserch into prctice? Types of evidence needed. Annu Rev Public Helth 2007;28: McKeown T, Record RG, Turner RD. An interprettion of the decline of mortlity in Englnd nd Wles during the twentieth century. Popul Stud (Cmb) 1975;29: Grundy E. Commentry: the McKeown debte: time for buril. Int J Epidemiol 2005;34: Mckenbch JP. The contribution of medicl cre to mortlity decline: McKeown revisited. J Clin Epidemiol 1996;49: Mckenbch JP, Stronks K, Kunst AE. The contribution of medicl cre to inequlities in helth: differences between socio-economic groups in decline of mortlity from conditions menble to medicl intervention. Soc Sci Med 1989;29: Howse C. The ultimte destintion of ll nursing : the development of district nursing in Englnd, Nurs Hist Rev 2007;15: Blck D, Morris JN, Smith C, Townsend P, Whitehed M. Inequlities in helth: the blck report, the helth divide. London: Penguin; Mrtinson ML. Income inequlity in helth t ll ges: comprison of the United Sttes nd Englnd. Am J Public Helth 2012;102: Mckenbch JP, Kunst AE, Cvelrs AE, Groenhof F, Geurts JJ. Socioeconomic inequlities in morbidity nd mortlity in western Europe. The EU Working Group on Socioeconomic Inequlities in Helth. Lncet 1997;349:

11 SDH: Considering the Cuses of the Cuses Mckenbch JP, Cvelrs AE, Kunst AE, Groenhof F. Socioeconomic inequlities in crdiovsculr disese mortlity; n interntionl study. Eur Hert J 2000;21: Mckenbch JP, Stirbu I, Roskm AJ, Schp MM, Menvielle G, Leinslu M, et l. Socioeconomic inequlities in helth in 22 Europen countries. N Engl J Med 2008;358: Orgnistion for Economic Co-opertion nd Development. OECD fctbook : economic, environmentl nd socil sttistics: life expectncy. Pris: OECD Publishing; Orgnistion for Economic Co-opertion nd Development. OECD fctbook : economic, environmentl nd socil sttistics: infnt mortlity. Pris: OECD Publishing; Woolf SH, Aron L, editors; Pnel on Understnding Cross-Ntionl Helth Differences Among High-Income Countries, Committee on Popultion, Division of Behviorl nd Socil Sciences nd Eduction, Bord on Popultion Helth nd Public Helth Prctice, Ntionl Reserch Council nd Institute of Medicine. U.S. helth in interntionl perspective: shorter lives, poorer helth. Wshington: Ntionl Acdemies Press; Rittenhouse DR, Brvemn P, Mrchi K. Improvements in prentl insurnce coverge nd utiliztion of cre in Cliforni: n unsung public helth victory. Mtern Child Helth J 2003;7: Alexnder GR, Kogn MD, Nbuker S. Rcil differences in prentl cre use in the United Sttes: re disprities decresing? Am J Public Helth 2002;92: Annth CV, Misr DP, Demissie K, Smulin JC. Rtes of preterm delivery mong blck women nd white women in the United Sttes over two decdes: n ge-period-cohort nlysis. Am J Epidemiol 2001;154: Alexnder GR, Korenbrot CC. The role of prentl cre in preventing low birth weight. Future Child 1995;5: Alexnder GR, Kotelchuck M. Assessing the role nd effectiveness of prentl cre: history, chllenges, nd directions for future reserch. Public Helth Rep 2001;116: Fiscell K. Does prentl cre improve birth outcomes? A criticl review. Obstet Gynecol 1995;85: Behrmn RE, Butler AS, editors; Committee on Understnding Premture Birth nd Assuring Helthy Outcomes, Bord on Helth Sciences Policy, Institute of Medicine. Preterm birth: cuses, consequences, nd prevention. Wshington: Ntionl Acdemies Press; Lu MC, Hlfon N. Rcil nd ethnic disprities in birth outcomes: life-course perspective. Mtern Child Helth J 2003;7: Lu MC, Tche V, Alexnder GR, Kotelchuck M, Hlfon N. Preventing low birth weight: is prentl cre the nswer? J Mtern Fetl Neontl Med 2003;13: McGinnis JM, Willims-Russo P, Knickmn JR. The cse for more ctive policy ttention to helth promotion. Helth Aff (Millwood) 2002;21: Brvemn P, Egerter S, Brcly C. Wht shpes helth-relted behviors? The role of socil fctors. Exploring the socil determinnts of helth: issue brief no. 1. Princeton (NJ): Robert Wood Johnson Foundtion; Stringhini S, Sbi S, Shipley M, Brunner E, Nbi H, Kivimki M, et l. Assocition of socioeconomic position with helth behviors nd mortlity. JAMA 2010;303: Jeml A, Thun MJ, Wrd EE, Henley SJ, Cokkinides VE, Murry TE. Mortlity from leding cuses by eduction nd rce in the United Sttes, Am J Prev Med 2008;34: Gle S, Trcy M, Hoggtt KJ, Dimggio C, Krpti A. Estimted deths ttributble to socil fctors in the United Sttes. Am J Public Helth 2011;101: Mrmot MG, Rose G, Shipley M, Hmilton PJ. Employment grde nd coronry hert disese in British civil servnts. J Epidemiol Community Helth 1978;32: Pmuk E, Mkuc D, Heck K, Reuben C, Lochner K. Helth, United Sttes, 1998 with socioeconomic sttus nd helth chrtbook. Hyttsville (MD): Ntionl Center for Helth Sttistics (US); Brvemn PA, Cubbin C, Egerter S, Willims DR, Pmuk E. Socioeconomic disprities in helth in the United Sttes: wht the ptterns tell us. Am J Public Helth 2010;100 Suppl 1:S Minkler M, Fuller-Thomson E, Gurlnik JM. Grdient of disbility cross the socioeconomic spectrum in the United Sttes. N Engl J Med 2006;355: Brvemn PA, Cubbin C, Egerter S, Chidey S, Mrchi KS, Metzler M, et l. Socioeconomic sttus in helth reserch: one size does not fit ll. JAMA 2005;294: Willims DR, Collins C. U.S. socioeconomic nd rcil differences in helth: ptterns nd explntions. Annu Rev Sociol 1995;21: Fuller-Thomson E, Nuru-Jeter A, Minkler M, Gurlnik JM. Blckwhite disprities in disbility mong older Americns: further untngling the role of rce nd socioeconomic sttus. J Aging Helth 2009;21: Prdies Y. A systemtic review of empiricl reserch on self-reported rcism nd helth. Int J Epidemiol 2006;35: Willims DR, Mohmmed SA. Discrimintion nd rcil disprities in helth: evidence nd needed reserch. J Behv Med 2009;32: Brvemn P. Blck-white disprities in birth outcomes: is rcismrelted stress missing piece of the puzzle? In: Lemelle AJ, Reed W, Tylor S, editors. Hndbook of Africn Americn helth: socil nd behviorl interventions. New York: Springer; p Jones CP. Levels of rcism: theoretic frmework nd grdener s tle. Am J Public Helth 2000;90: Nuru-Jeter A, Dominguez TP, Hmmond WP, Leu J, Skff M, Egerter S, et l. It s the skin you re in : Africn Americn women tlk bout their experiences of rcism. An explortory study to develop mesures of rcism for birth outcome studies. Mtern Child Helth J 2009;13: Willims DR, Mohmmed SA. Discrimintion nd rcil disprities in helth: evidence nd needed reserch. J Behv Med 2009;32: Foege WH. Socil determinnts of helth nd helth-cre solutions. Public Helth Rep 2010;125 Suppl 4: Rosen G. A history of public helth. Expnded ed. Bltimore: Johns Hopkins University Press; Hmlin C. Public helth nd socil justice in the ge of Chdwick: Britin, Cmbridge (UK): Cmbridge University Press; Kwchi I, Adler NE, Dow WH. Money, schooling, nd helth: mechnisms nd cusl evidence. Ann N Y Acd Sci 2010;1186: Brvemn P, Egerter S, Brcly C. Income, welth nd helth. Exploring the socil determinnts of helth: issue brief no. 4. Princeton (NJ): Robert Wood Johnson Foundtion; Almond D Jr, Chy KY, Greenstone M. Civil rights, the wr on poverty, nd blck-white convergence in infnt mortlity in the rurl South nd Mississippi. Cmbridge (MA): Msschussetts Institute of Technology, Deprtment of Economics; Mrtikinen PT, Vlkonen T. Excess mortlity of unemployed men nd women during period of rpidly incresing unemployment. Lncet 1996;348: Fernld LC, Gertler PJ, Neufeld LM. 10-yer effect of Oportuniddes, Mexico s conditionl csh trnsfer progrmme, on child growth, cognition, lnguge, nd behviour: longitudinl follow-up study. Lncet 2009;374: Kroly LA, Kilburn MR, Cnnon JS. Erly childhood interventions: proven results, future promise. Snt Monic (CA): Rnd Corportion; Reynolds AJ, Temple JA, Ou SR, Robertson DL, Mersky JP, Topitzes JW, et l. Effects of school-bsed, erly childhood intervention on dult helth nd well-being: 19-yer follow-up of low-income fmilies. Arch Peditr Adolesc Med 2007;161: Kehrer BH, Wolin CM. Impct of income mintennce on low birth weight: evidence from the Gry Experiment. J Hum Resour 1979;14: Miller C, Huston A, Duncn G, McLoyd V, Weisner TS. New hope for the working poor: effects fter eight yers for fmilies nd children. New York: MDRC; Kelly MP, Bonnefoy J, Morgn A, Florenzno F. The development of the evidence bse bout the socil determinnts of helth. Genev: World Helth Orgniztion, Commission on Socil Determinnts of Helth, Mesurement nd Evidence Knowledge Network; Link BG, Pheln J. Socil conditions s fundmentl cuses of disese. J Helth Soc Behv 1995;Spec No: Miller GE, Chen E, Fok AK, Wlker H, Lim A, Nicholls EF, et l. Low erly-life socil clss leves biologicl residue mnifested by decresed glucocorticoid nd incresed proinflmmtory signling. Proc Ntl Acd Sci U S A 2009;106: Lidsky TI, Schneider JS. Led neurotoxicity in children: bsic mechnisms nd clinicl correltes. Brin 2003;126(Pt 1):5-19.

12 30 Nursing in 3D: Diversity, Disprities, nd Socil Determinnts 79. Afeiche M, Peterson KE, Sánchez BN, Schns L, Cntonwine D, Ettinger AS, et l. Windows of led exposure sensitivity, ttined height, nd body mss index t 48 months. J Peditr 2012;160: Brown P. Rce, clss, nd environmentl helth: review nd systemtiztion of the literture. Environ Res 1995;69: Lnpher BP, Khn RS, Berger O, Auinger P, Bortnick SM, Nhhs RW. Contribution of residentil exposures to sthm in U.S. children nd dolescents. Peditrics 2001;107:E Bingenheimer JB, Brennn RT, Erls FJ. Firerm violence exposure nd serious violent behvior. Science 2005;308: Pollck CE, Cubbin C, Ahn D, Winkleby M. Neighbourhood deprivtion nd lcohol consumption: does the vilbility of lcohol ply role? Int J Epidemiol 2005;34: Mrco CA, Wolfson AR, Sprling M, Azuje A. Fmily socioeconomic sttus nd sleep ptterns of young dolescents. Behv Sleep Med 2011;10: Hle L. Who hs time to sleep? J Public Helth (Oxf) 2005;27: Cook WK, Heller J, Bhti R, Frhng L. A helth impct ssessment of the Helthy Fmilies Act of Oklnd (CA): Humn Impct Prtners nd Sn Frncisco Deprtment of Public Helth; Chung YC, Cubbin C, Ahn D, Winkleby MA. Effects of neighbourhood socioeconomic sttus nd convenience store concentrtion on individul level smoking. J Epidemiol Community Helth 2005;59: Gordon-Lrsen P, Nelson MC, Pge P, Popkin BM. Inequlity in the built environment underlies key helth disprities in physicl ctivity nd obesity. Peditrics 2006;117: Cummins S, Mcintyre S. Food environments nd obesity neighbourhood or ntion? Int J Epidemiol 2006;35: Evns GW, Schmberg MA. Childhood poverty, chronic stress, nd dult working memory. Proc Ntl Acd Sci U S A 2009;106: Cutler DM, Lnge F, Mer E, Richrds-Shubik S, Ruhm CJ. Rising eductionl grdients in mortlity: the role of behviorl risk fctors. J Helth Econ 2011;30: Mtthews KA, Gllo LC, Tylor SE. Are psychosocil fctors meditors of socioeconomic sttus nd helth connections? A progress report nd blueprint for the future. Ann N Y Acd Sci 2010;1186: McEwen BS, Ginros PJ. Centrl role of the brin in stress nd dpttion: links to socioeconomic sttus, helth, nd disese. Ann N Y Acd Sci 2010;1186: McEwen BS, Seemn T. Protective nd dmging effects of meditors of stress. Elborting nd testing the concepts of llostsis nd llosttic lod. Ann N Y Acd Sci 1999;896: Seemn T, Epel E, Gruenewld T, Krlmngl A, McEwen BS. Socio-economic differentils in peripherl biology: cumultive llosttic lod. Ann N Y Acd Sci 2010;1186: Miller G, Chen E, Cole SW. Helth psychology: developing biologiclly plusible models linking the socil world nd physicl helth. Annu Rev Psychol 2009;60: Gehlert S, Sohmer D, Scks T, Mininger C, McClintock M, Olopde O. Trgeting helth disprities: model linking upstrem determinnts to downstrem interventions. Helth Aff (Millwood) 2008;27: Institute of Medicine, Bord on Neuroscience nd Behviorl Helth, Committee on Helth nd Behvior: Reserch, Prctice nd Policy. Helth nd behvior: the interply of biologicl, behviorl, nd societl influences. Wshington: Ntionl Acdemies Press; McEwen BS. Protective nd dmging effects of stress meditors. N Engl J Med 1998;338: Cohen S, Doyle WJ, Skoner DP. Psychologicl stress, cytokine production, nd severity of upper respirtory illness. Psychosom Med 1999;61: Broyles ST, Stino AE, Drzb KT, Gupt AK, Sothern M, Ktzmrzyk PT. Elevted C-rective protein in children from risky neighborhoods: evidence for stress pthwy linking neighborhoods nd inflmmtion in children. PLoS One 2012;7:e Kpln GA, Keil JE. Socioeconomic fctors nd crdiovsculr disese: review of the literture. Circultion 1993;88(4 Pt 1): Wolffe AP, Mtzke MA. Epigenetics: regultion through repression. Science 1999;286: Tung J, Brreiro LB, Johnson ZP, Hnsen KD, Michopoulos V, Toufexis D, et l. Socil environment is ssocited with gene regultory vrition in the rhesus mcque immune system. Proc Ntl Acd Sci U S A 2012;109: Surtees PG, Winwright NW, Pooley KA, Luben RN, Khw KT, Eston DF, et l. Eductionl ttinment nd men leukocyte telomere length in women in the Europen Prospective Investigtion into Cncer (EPIC)-Norfolk popultion study. Brin Behv Immun 2012;26: Steptoe A, Hmer M, Butcher L, Lin J, Brydon L, Kivimäki M, et l. Eductionl ttinment but not mesures of current socioeconomic circumstnces re ssocited with leukocyte telomere length in helthy older men nd women. Brin Behv Immun 2011;25: Cherks LF, Aviv A, Vldes AM, Hunkin JL, Grdner JP, Surdulescu GL, et l. The effects of socil sttus on biologicl ging s mesured by white-blood-cell telomere length. Aging Cell 2006;5: Prks CG, DeRoo LA, Miller DB, McCnlies EC, Cwthon RM, Sndler DP. Employment nd work schedule re relted to telomere length in women. Occup Environ Med 2011;68: Prks CG, Miller DB, McCnlies EC, Cwthon RM, Andrew ME, DeRoo LA, et l. Telomere length, current perceived stress, nd urinry stress hormones in women. Cncer Epidemiol Biomrkers Prev 2009;18: Epel ES, Blckburn EH, Lin J, Dhbhr FS, Adler NE, Morrow JD, et l. Accelerted telomere shortening in response to life stress. Proc Ntl Acd Sci U S A 2004;101: Humphreys J, Epel ES, Cooper BA, Lin J, Blckburn EH, Lee KA. Telomere shortening in formerly bused nd never bused women. Biol Res Nurs 2012;14: Price LH, Ko HT, Burgers DE, Crpenter LL, Tyrk AR. Telomeres nd erly-life stress: n overview. Biol Psychitry 2013;73: Aubert G, Lnsdorp PM. Telomeres nd ging. Physiol Rev 2008;88: Seemn TE, Crimmins E, Hung MH, Singer B, Bucur A, Gruenewld T, et l. Cumultive biologicl risk nd socio-economic differences in mortlity: McArthur studies of successful ging. Soc Sci Med 2004;58: Singer B, Ryff CD. Hierrchies of life histories nd ssocited helth risks. Ann N Y Acd Sci 1999;896: Rhkonen O, Lhelm E, Huuhk M. Pst or present? Childhood living conditions nd current socioeconomic sttus s determinnts of dult helth. Soc Sci Med 1997;44: Globrdes B, Lynch JW, Dvey Smith G. Childhood socioeconomic circumstnces nd cuse-specific mortlity in dulthood: systemtic review nd interprettion. Epidemiol Rev 2004;26: Miller G, Chen E. Unfvorble socioeconomic conditions in erly life presge expression of proinflmmtory phenotype in dolescence. Psychosom Med 2007;69: Gurlnik JM, Butterworth S, Wdsworth ME, Kuh D. Childhood socioeconomic sttus predicts physicl functioning hlf century lter. J Gerontol A Biol Sci Med Sci 2006;61: Gilmn SE, Kwchi I, Fitzmurice GM, Buk SL. Socioeconomic sttus in childhood nd the lifetime risk of mjor depression. Int J Epidemiol 2002;31: Cohen S, Doyle WJ, Turner RB, Alper CM, Skoner DP. Childhood socioeconomic sttus nd host resistnce to infectious illness in dulthood. Psychosom Med 2004;66: Frnzini L, Ribble JC, Keddie AM. Understnding the Hispnic prdox. Ethn Dis 2001;11: Gllo LC, Penedo FJ, Espinos de los Monteros K, Arguelles W. Resiliency in the fce of disdvntge: do Hispnic culturl chrcteristics protect helth outcomes? J Pers 2009;77: Annd S, Rvllion M. Humn development in poor countries: on the role of privte incomes nd public services. J Econ Perspect 1993;7: Cole SW, Arevlo JM, Mnu K, Telzer EH, King L, Bower JE, et l. Antgonistic pleiotropy t the humn IL6 promoter confers genetic resilience to the pro-inflmmtory effects of dverse socil conditions in dolescence. Dev Psychol 2011;47: Demkkos P, Nzroo J, Breeze E, Mrmot M. Socioeconomic sttus nd helth: the role of subjective socil sttus. Soc Sci Med 2008;67: Hertzmn C. The biologicl embedding of erly experience nd its effects on helth in dulthood. Ann N Y Acd Sci 1999;896:85-95.

13 SDH: Considering the Cuses of the Cuses Kuh D, Hrdy R, Lngenberg C, Richrds M, Wdsworth ME. Mortlity in dults ged yers relted to socioeconomic conditions in childhood nd dulthood: post wr birth cohort study. BMJ 2002;325: Lwlor DA, Btty GD, Morton SM, Clrk H, Mcintyre S, Leon DA. Childhood socioeconomic position, eductionl ttinment, nd dult crdiovsculr risk fctors: the Aberdeen children of the 1950s cohort study. Am J Public Helth 2005;95: Melchior M, Moffitt TE, Milne BJ, Poulton R, Cspi A. Why do children from socioeconomiclly disdvntged fmilies suffer from poor helth when they rech dulthood? A life-course study. Am J Epidemiol 2007;166: Turrell G, Lynch JW, Leite C, Rghunthn T, Kpln GA. Socioeconomic disdvntge in childhood nd cross the life course nd ll-cuse mortlity nd physicl function in dulthood: evidence from the Almed County Study. J Epidemiol Community Helth 2007;61: Egerter S, Brvemn P, Sdegh-Nobri T, Grossmn-Khn R, Dekker M. Eduction nd helth. Exploring the socil determinnts of helth: issue brief no. 5. Princeton (NJ): Robert Wood Johnson Foundtion; Philippe P, Mnsi O. Nonlinerity in the epidemiology of complex helth nd disese processes. Theor Med Bioeth 1998;19: Gle S, Riddle M, Kpln GA. Cusl thinking nd complex system pproches in epidemiology. Int J Epidemiol 2010;39: Arcy M, Briggs Xde S. Despite obstcles, considerble potentil exists for more robust federl policy on community development nd helth. Helth Aff (Millwood) 2011;30: Bostic RW, Thornton RL, Rudd EC, Sternthl MJ. Helth in ll policies: the role of the U.S. Deprtment of Housing nd Urbn Development nd present nd future chllenges. Helth Aff (Millwood) 2012;31: Miller W, Simon P, Mleque S, editors. Beyond helth cre: new directions to helthier Americ. Wshington: Robert Wood Johnson Foundtion Commission to Build Helthier Americ; Committee on Integrting Primry Cre nd Public Helth, Bord on Popultion Helth nd Public Helth Prctice, Institute of Medicine. Primry cre nd public helth: exploring integrtion to improve popultion helth. Wshington: Ntionl Acdemies Press; Fiscell K, Tncredi D, Frnks P. Adding socioeconomic sttus to Frminghm scoring to reduce disprities in coronry risk ssessment. Am Hert J 2009;157: Beck AF, Klein MD, Schffzin JK, Tllent V, Gillm M, Khn RS. Identifying nd treting substndrd housing cluster using medicl-legl prtnership. Peditrics 2012;130: Pettignno R, Cley SB, Bliss LR. Medicl-legl prtnership: impct on ptients with sickle cell disese. Peditrics 2011;128:e Gottlieb L, Sndel M, Adler NE. Collecting nd pplying dt on socil determinnts of helth in helth cre settings. JAMA Intern Med 2013;173: Gruen RL, Person SD, Brennn TA. Physicin-citizens public roles nd professionl obligtions. JAMA 2004;291:94-8.