health outcomes, including many of the outcomes for which there are cross-national health differences, such as noncommunicable diseases, associated risk factors, injuries, and violence.

Understanding the reasons for the spatial patterns of health within countries may shed light on environmental factors that may contribute to differences across countries. Several factors may explain the strong spatial patterns that are observed within countries. A key contender is the spatial sorting of people based on their socioeconomic position, race, or ethnicity. However, evidence suggests that regional and neighborhood differences in health persist even after adjusting for these socioeconomic and demographic factors (Diez Roux and Mair, 2010; Mair et al., 2008; Paczkowski and Galea, 2010; Pickett and Pearl, 2001). This evidence suggests that broad environmental factors may play an important role in health. Moreover, environmental factors linked to space and place may in turn contribute to and reinforce socioeconomic and racial or ethnic health disparities (Bleich et al., 2012; Laveist et al., 2011). Thus, individual and environmental factors may be part of a reinforcing cycle that creates and perpetuates health differences. These reinforcing processes by which environmental factors and individual-, family-, and community-level factors reinforce each other over time may also play an important role in generating cross-national differences in health.

This chapter focuses on both the physical and social environment in the United States as potential contributors to its health disadvantage relative to other high-income countries. This chapter, like others before it, focuses on three questions:

•   Do environmental factors matter to health?

•   Are environmental factors worse in the United States than in other high-income countries?

•   Do environmental factors explain the U.S. health disadvantage?


Many aspects of the physical and social environment can affect people’s health.1 Spatial contexts linked to regions or neighborhoods are among


1Although analytically distinct, physical and social environments may also influence and reinforce each other: for example, physical features related to walkability may contribute to social norms regarding walking, which may in turn promote more walkable urban designs and community planning.

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