BOX 6-1
Social Factors That Affect Health Outcomes

Upstream social factors—Laws, policies, and underlying values that shape the following:

•   Income and wealth

•   Education

•   Employment

•   Household composition

•   Experiences based on race or ethnic group

•   Social mobility

•   Stressful experiences related to any of the above

•   Income inequality

Midstream social factors—Factors that are strongly influenced by upstream factors and that are likely to affect health:

•   Housing

•   Transportation

•   Other conditions in homes, schools, workplaces, neighborhoods, and communities, including conditions that produce stress and family disruption (e.g., parenting skills, parenting stress, leisure time, quality of schooling, physical and psychosocial working conditions)

diet (Treuhaft and Karpyn, 2010), to buy or rent healthy housing2 in a healthy neighborhood (Shaw, 2004), and to engage in regular exercise (e.g., through gym membership or living where it is safe and pleasant to exercise outdoors). However, careful analysis of longitudinal data has revealed that the association between adverse economic conditions and mortality persists even after adjusting for unhealthy behaviors (Lantz et al., 2010), suggesting that economic stresses may also affect health through other pathways. Access to employment, educational opportunities, and medical care can be constrained by one’s income, particularly in the absence of adequate public transportation (Gordon-Larsen et al., 2006). Exposure to poverty during childhood may have particularly strong and enduring effects on health across the entire life course (Cohen et al., 2010; Pollitt et al., 2005). Material hardship is strongly related to family strife and disruption (Braveman


2Healthy housing refers to domiciles that are free of health and safety threats, such as lead, which can affect children’s cognitive function, and free of excessive dust, mites, and mold, which can provoke and exacerbate respiratory disease (Lanphear et al., 2001).

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