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PAPER CONTRIBUTION B

Understanding and Reducing Socioeconomic and Racial/Ethnic Disparities in Health

James S.House and David R.Williams

The initial paper by Kaplan and colleagues and the burgeoning literatures on socioeconomic and racial/ethnic disparities in health establish that such disparities are large, persistent, and even increasing in the United States and other developed countries, most notably the United Kingdom (Marmot et al., 1987; Preston and Haines, 1991; Adler et al., 1993; Pappas et al., 1993; Evans et al., 1994; Williams and Collins, 1995). Differences across socioeconomic and racial/ethnic groups or combinations thereof range up to 10 or more years in life expectancy and 20 or more years in the age at which significant limitations in functional health are first experienced (see Table 1; House et al., 1990, 1994). Both within and across countries, individuals with the most advantaged socioeconomic and racial/ethnic status are experiencing levels of health and longevity

Dr. House is director of the Survey Research Center in the Institute for Social Research and professor of sociology, University of Michigan, and Dr. Williams is professor of sociology and reserach scientist at the Institute for Social Research, University of Michigan. This paper was prepared for the symposium “Capitalizing on Social Science and Behavioral Research to Improve the Public's Health ,” the Institute of Medicine and the Commission on Behavioral and Social Sciences and Education of the National Research Council, Atlanta, Georgia, Februray 2–3, 2000. This work has been supported by a Robert Wood Johnson Foundation Investigation in Health Policy Research Award (Dr. House) and by grant MH-57425 from the National Institute of Mental Research and the John D. and Catherine T.MacArthur Foundation Research Network on Socioeconomic Status and Health (Dr. Williams). We are indebted to Debbie Fitch for her work in preparing the manuscript, references, figures, and table.



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Promoting Health: Intervention Strategies from Social and Behavioral Research PAPER CONTRIBUTION B Understanding and Reducing Socioeconomic and Racial/Ethnic Disparities in Health James S.House and David R.Williams The initial paper by Kaplan and colleagues and the burgeoning literatures on socioeconomic and racial/ethnic disparities in health establish that such disparities are large, persistent, and even increasing in the United States and other developed countries, most notably the United Kingdom (Marmot et al., 1987; Preston and Haines, 1991; Adler et al., 1993; Pappas et al., 1993; Evans et al., 1994; Williams and Collins, 1995). Differences across socioeconomic and racial/ethnic groups or combinations thereof range up to 10 or more years in life expectancy and 20 or more years in the age at which significant limitations in functional health are first experienced (see Table 1; House et al., 1990, 1994). Both within and across countries, individuals with the most advantaged socioeconomic and racial/ethnic status are experiencing levels of health and longevity Dr. House is director of the Survey Research Center in the Institute for Social Research and professor of sociology, University of Michigan, and Dr. Williams is professor of sociology and reserach scientist at the Institute for Social Research, University of Michigan. This paper was prepared for the symposium “Capitalizing on Social Science and Behavioral Research to Improve the Public's Health ,” the Institute of Medicine and the Commission on Behavioral and Social Sciences and Education of the National Research Council, Atlanta, Georgia, Februray 2–3, 2000. This work has been supported by a Robert Wood Johnson Foundation Investigation in Health Policy Research Award (Dr. House) and by grant MH-57425 from the National Institute of Mental Research and the John D. and Catherine T.MacArthur Foundation Research Network on Socioeconomic Status and Health (Dr. Williams). We are indebted to Debbie Fitch for her work in preparing the manuscript, references, figures, and table.

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Promoting Health: Intervention Strategies from Social and Behavioral Research TABLE 1. United States Life Expectancy, at Age 45 by Family Income (1980 dollars)a   Females Males Family Income White Black Diff. White Black Diff. Allb 36.3 32.6 3.7 31.1 26.2 4.9 <$ 10,000 35.8 32.7 3.1 27.3 25.2 2.1 $10,000–$14,999 37.4 33.5 3.9 30.3 28.1 2.2 $15,000–$24,999 37.8 36.3 1.5 32.4 31.3 1.1 ≥$25,000 38.5 36.5 2.0 33.9 32.6 1.3 NOTE: Diff. = difference. a1979–1989; Taken from the National Center for Health Statistics. b1989–1991; Taken from the National Center for Health Statistics. that increasingly approach the current biologically attainable maxima. Thus, the major opportunity for improving the health of human populations in the United States and most other societies lies in improving the longevity and health of those of below-average socioeconomic or racial/ethnic status. Accordingly, the reduction of socioeconomic and racial/ethnic disparities in health has been identified by the U.S. Public Health Service and the National Institutes of Health as a major priority for public health practice and research in the first decade of the twenty-first century (USDHHS, 1999; Varmus, 1999). This will involve some combination of either reducing the degree to which disparities in socioeconomic and racial/ethnic status are converted into health disparities or reducing the extent of socioeconomic or racial/ethnic disparities themselves. This will further entail understanding both (1) the psychosocial and biomedical pathways that translate socioeconomic and racial/ethnic disparities into disparities in health, and (2) the broader social, cultural economic, and political processes that determine the nature and extent of socioeconomic and racial/ethnic disparities in our society, and the ways in which individuals become distributed across socioeconomic levels and defined into racial/ethnic groups. This paper seeks to elucidate what we already know and need yet to learn about reducing socioeconomic and racial/ethnic disparities in health. We first provide a brief overview of the nature of both socioeconomic and racial/ethnic disparities in health and how they are related to each other. Second, we assess current understanding of the pathways or mechanisms by which the socioeconomic or racial/ethnic status of individuals affects their health and the implications of this understanding for reducing socioeconomic and racial/ethnic disparities in health. Third, we explore what is known about how and why communities and societies come to be stratified both socioeconomically and in terms of race/ethnicity, and how these communal and societal patterns of socioeconomic and racial/ethnic stratification affect the socioeconomic and racial/ethnic status of individuals and their health. Finally, we conclude with an assessment of what we

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Promoting Health: Intervention Strategies from Social and Behavioral Research know and need to know about how to reduce socioeconomic and racial/ethnic disparities in health and, hence, to improve population health. Several themes pervade our discussion. First, there are multiple indicators of socioeconomic position and hence multiple indices of socioeconomic disparities in health, and these are best comprehended in a multivariate, causal, and life course framework. Second, socioeconomic and racial/ethnic disparities in health, and the reasons for and means of reducing them, are inextricably related but also distinctive. This also can best be comprehended in a multivariate causal framework. Third, it is important to understand the pathways or mechanisms linking socioeconomic and racial/ethnic status to health. What is most striking and important here is to recognize that socioeconomic and racial/ethnic status shape and operate through a very broad range of pathways or mechanisms, including almost all known major psychosocial and behavioral risk factors for health. Thus, socioeconomic and racial/ethnic status are in the terms of Link and Phelan (1995) the “fundamental causes ” of corresponding socioeconomic and racial/ethnic disparities in risk factors and hence health and, consequently, also the fundamental levers for reducing these health disparities. Finally, existing evidence strongly suggests that the nature of the socioeconomic and racial/ethnic stratification of individuals can be changed in ways beneficial to health and, coincidentally, to a broad range of other indicators of individual and societal well-being. THE NATURE OF SOCIOECONOMIC AND RACIAL/ETHNIC DISPARITIES AND THEIR RELATION TO HEALTH We take the size, persistence, and even increase of socioeconomic and racial/ethnic disparities as given in Paper Contribution A. Here we seek to clarify the nature of socioeconomic and racial/ethnic status and their relations to each other and to health. A Multivariate, Causal, and Life Course Framework Socioeconomic status (SES) refers to individuals' position in a system of social stratification that differentially allocates the major resources enabling people to achieve health or other desired goals. These resources centrally include education, occupation, income, and assets or wealth, which are related to each other and to health in a causal framework first elucidated by Blau and Duncan (1967) and shown in its simplest form in Figure 1A. This model suggests that over the life course, individuals first acquire varying levels and types of education, which in turn help them to enter various types of occupations, which then yield income, which finally enables them to accumulate assets or wealth. Each subsequent variable in this causal chain is generally most affected by the immediately prior variable, with potential residual effects of earlier variables. This model is simple because it omits potential feedback loops other than from assets or wealth to income (e.g., a person's occupation may facilitate further educational attainment) and fails

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Promoting Health: Intervention Strategies from Social and Behavioral Research FIGURE 1A. Simple intragenerational causal model relating major indicators of socioeconomic position to each other and to health. to incorporate variations in each of these indicators that will occur over the life course (e.g., progressions or regressions in terms of occupation or income). Although this causal framework has been used routinely in the study of socioeconomic attainment, it has seldom been explicitly applied to the study of socioeconomic disparities. It is important, however, that it be utilized more explicitly in future research on the relation of socioeconomic status to health, and especially in thinking about how socioeconomic disparities in health have been or could be reduced. The framework helps, for example, to understand why income is perhaps the strongest and most robust predictor of health (McDonough et al., 1997; Lantz et al., 1998), because to some degree the impacts of all other variables are mediated through it. Also, some health outcomes are more strongly affected by certain socioeconomic indicators than others (education, for example, more strongly affects health behaviors, patterns of which form early in life, and the diseases or health indicators affected most by them). Overall, in the United States, education and income have proved most predictive of health, with occupation often adding little additional explanatory power and assets or wealth somewhat more. More research is needed, however, to estimate explicitly the relative effects on health of these different indicators of socioeconomic position, and how much the total effect of any given variable is spuriously produced by temporally antecedent confounding variables, mediated via temporally subsequent intervening variables, or acts more directly on health (see Sorlie et al., 1995; Lantz et al., 1998 and in press; and Robert and House, 2000 a,b). From the point of view of reducing health disparities, we need to have such an analysis of the variance in health explained by different socioeconomic factors in order to understand or predict the health effects of planned or unplanned change in each indicator. Further, by adding other variables to Figure 1A,

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Promoting Health: Intervention Strategies from Social and Behavioral Research FIGURE 1B Simple intergenerational extension of model in Figure 1A.

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Promoting Health: Intervention Strategies from Social and Behavioral Research FIGURE 1C Extension of model in Figure 1B incorporating race/ethnicity, sex/gender, and age. NOTE: for clarity of presentation, no arrows are drawn from age and sex/gender to subsequent variables, but these would and should be exactly parallel to those for race/ethnicity.

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Promoting Health: Intervention Strategies from Social and Behavioral Research we can extend our understanding of how disparities in health across these indicators of socioeconomic position may be generated by antecedent factors or mediated via subsequent factors. Several such elaborations are important in thinking about reducing other socioeconomic and racial disparities in health. First, socioeconomic position (SEP) has to be thought of as an intergenerational as well as intragenerational phenomenon. Thus, parental socioeconomic position may importantly shape childhood well-being and hence educational and later adult socioeconomic attainment and health, as shown in Figure 1B. The work of Barker (e.g., Barker and Osmond, 1986) and others (Kaplan and Salonen, 1990; Elo and Preston, 1992; Blane et al., 1996; Kuh and Ben-Shlomo, 1997) has indicated that childhood socioeconomic position and experiences can have long-term effects on adult health (see also Paper Contribution C). This is sometimes interpreted to mean that childhood socioeconomic position is a more important determinant of health than adult socioeconomic position. However, Figure 1B suggests that most such effects are likely to be channeled through and reinforced by later socioeconomic attainment, and the unique impact of childhood SEP or its sequelae must be evaluated net of later socioeconomic or other experiences. When this is done, the unique effects of childhood SEP on adult health are often found to be small or even nonexistent relative to the effects of later adult socioeconomic attainment and experiences (e.g., Lynch et al., 1994). *Thus, although the impact of socioeconomic position on childhood health and well-being is a very important problem in its own right, it cannot and should not be viewed as a major explanation of adult socioeconomic or racial/ethnic disparities in health or hence as the major, preferred, or necessary route for reducing such adult disparities. However, Figure 1B is also highly simplified, neglecting the changing socioeconomic position of the families of many children. Thus, the socioeconomic position of a child often changes from preschool to elementary school to secondary school and onward through adulthood. Socioeconomic advantage and disadvantage may be viewed as ebbing and flowing or cascading over a person's life course. Although recent socioeconomic position is usually the best predictor of future outcomes, sustained socioeconomic deprivation over time is likely to be even more damaging (Wolfson et al., 1993, Lynch et al., 1997), and uncertainty or variability in socioeconomic position may be deleterious even to those of generally solid middle- or higher-level SEP (McDonough et al., 1997). Thus, knowledge of the full life course of socioeconomic position is ideally desirable for understanding socioeconomic disparities in health and a target for efforts to alleviate such disparities. Finally, Figures 1A and 1B must be further elaborated, as in Figure 1C, to take account of the impact of more ascribed and relatively fixed social *Link and Phelan (in progress) have similarly showed that although cognitive ability contributes to socioeconomic attainment, its effects on health are mediated entirely through such attainments, and it in no way can explain away or make spurious the considerable impact of adult SEP on health.

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Promoting Health: Intervention Strategies from Social and Behavioral Research statuses—most notably for our purposes, race/ethnicity, but also age and gender. Figure 1C reveals two simple but very important truths about racial/ethnic disparities in health. First, racial/ethnic status is a major determinant of every indicator of socioeconomic position, even net of all prior variables in the model. For example, not only are African Americans disadvantaged in terms of level of education, but even given the same education, they are disadvantaged occupationally and in terms of income, and still disadvantaged in income even within the same educational and occupational levels (Featherman and Hauser, 1978). Most egregiously, their assets/wealth lag far behind other Americans of equivalent income, occupation, and education (Oliver and Shapiro, 1995; Conley, 1999). Not surprisingly, then, a great deal of racial/ethnic disparity in health is explainable in terms of the socioeconomic disadvantages associated with membership in the most historically disadvantaged racial/ethnic groups (Williams and Collins, 1995). However, the second important truth of Figure 1C is that race/ethnicity has effects on health that are independent of socioeconomic differences between racial/ethnic groups (Williams and Collins, 1995; Williams et al., 1997). For example, African Americans generally exhibit poorer health outcomes even when compared to whites with statistically equivalent levels of socioeconomic position (see below and Table 1). Thus, race carries its own burdens for health beyond those associated with socioeconomic disadvantage. We can properly estimate and understand how race/ethnicity and socioeconomic position combine to affect health only within a multivariate framework such as Figure 1C. Further, such a framework can also reveal that race/ethnicity sometimes has salutary effects on health that may compensate in part for the deleterious effects of socioeconomic disadvantages. For example, African Americans exhibit better levels of mental health, and Latinos better levels of infant and child health, than would be expected based on their socioeconomic position. The next major section of this paper focuses on elucidating the pathways or mechanisms through which both socioeconomic position and race/ethnicity affect health, for better as well as for worse. Due to constraints of space and desire for clarity, Figure 1C fails to represent other important issues for understanding and reducing socioeconomic disparities in health. First is the issue of reciprocal or reverse causality, especially between socioeconomic position and health. Ours and others' discussions of reducing socioeconomic and racial/ethnic disparities in health are predicated on the assumption that, by far, the predominant causal flow is from socioeconomic position and race/ethnicity to health rather than vice versa. This assumption is self-evident for a fixed attribute such as race/ethnicity and is generally borne out in empirical research on socioeconomic position, for example, by introducing baseline controls on health into the framework of Figure 1 (see House and Roberts, 2000:116–117), though clearly health events or shocks can and do affect subsequent labor force participation and income (often more in the short term than in the long term). Second, time and space prevent us from fully and systematically attending to variations by age, sex, race/ethnicity, and other factors

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Promoting Health: Intervention Strategies from Social and Behavioral Research in the presence of size of the causal paths/effects in Figure 1, though we will on occasion note such variations (see Robert and House, 2000b:118–120 for more discussion of such issues). Shape of the Relationship Between SES and Health Before turning more explicitly to how we may explain and reduce socioeconomic and racial/ethnic disparities in health, it is important to clarify our understanding of the shape of the relationship between socioeconomic position and health. An intriguing finding of some research on socioeconomic inequalities in health is that it is not simply that those who are in the lowest socioeconomic groups have worse health than those in higher socioeconomic groups. Rather, a relationship between socioeconomic position and health has been observed across the socioeconomic hierarchy, with even those in relatively high-socioeconomic groups having better health than those just below them in the socioeconomic hierarchy (Adler et al., 1994; Marmot et al., 1991). Perhaps the most important implication of this finding is that it is not just the material, psychological, and social conditions associated with severe deprivation or poverty (such as lack of access to safe housing, healthy food, and adequate medical care) that explain socioeconomic inequalities in health among those already at relatively high levels of socioeconomic position. Despite some evidence for gradient effects of socioeconomic position on health, it is also important to note the many studies indicating that the relationship of socioeconomic position, especially as indexed by income, to health is monotonic, but not a linear gradient. Although increasingly higher levels of socioeconomic position may be associated with increasingly better levels of health, there are also substantially diminishing returns of higher socioeconomic position to health. For example, studies have found diminishing and even nonexistent relationships between income and mortality (Wolfson et al., 1993; Backlund et al., 1996; Chapman and Hariharan, 1996; McDonough et al., 1997;) or morbidity (House et al., 1990, 1994; Mirowsky and Hu, 1996) at higher levels of income (e.g., above the median). This trend partially reflects a health “ceiling effect” caused by the fact that people in the upper socioeconomic strata maintain overall good health until quite late in life, leaving little opportunity for improvement in health among these groups throughout much of adulthood (House et al., 1994). Thus, it is most important to understand what accounts for socioeconomic inequalities in health across the broad lower range (e.g., lower 40–60%) of socioeconomic position, rather than focusing mainly or only on factors that might explain this relationship across the gradient or at higher levels.

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Promoting Health: Intervention Strategies from Social and Behavioral Research PATHWAYS LINKING INDIVIDUAL SOCIOECONOMIC AND RACIAL/ETHNIC STATUS TO HEALTH Pathways from SES to Health We have increased understanding of how and why socioeconomic status has such strong pervasive and even increasing impacts on health. Several aspects of this deserve emphasis. First, access to and utilization of medical care play only a limited role in explaining the impact of socioeconomic factors on health, although research is needed to reassess the size of the role played by medical care. Second, there is no single or small set of factors, psychosocial or physiological, that provides the pathways linking socioeconomic position to health. Rather, what makes socioeconomic position such a powerful determinant of health is that it shapes people's experience of, and exposure to, virtually all psychosocial and environmental risk factors for health—past, present, and future—and these in turn operate through a very broad range of physiological mechanisms to influence the incidence and course of virtually all major causes of disease and health. Thus, in the end, socioeconomic position itself is a fundamental cause (Link and Phelan, 1995) of levels of individual and population health and a fundamental lever for improving health in American society. The Limited but Insufficiently Understood Role of Medical Care Several types of evidence point to the limited role of medical care in understanding how and why socioeconomic position affects health. First, there is evidence that modern preventive and therapeutic medical care can account for only a minor fraction of the dramatic improvements in individual and population health over the last 250 years (McKeown, 1976, 1979, 1988; McKinlay and McKinlay, 1977). Even analysts admiring of the impact of medical science on health, for example, estimate that only about 5 years of the 30-year increase in life expectancy in the United States in the twentieth century has been due to preventive or therapeutic medical care (Bunker et al., 1994). The remainder is attributable primarily to increasing socioeconomic development and associated gains in nutrition, public health and sanitation, and living conditions. Second, improvements in access to medical care occasioned by the introduction of national health insurance or service plans have, quite unexpectedly, done little or nothing to reduce socioeconomic differences in health. The rediscovery of the importance of socioeconomic disparities in health as a major public health problem was probably stimulated most by the publication in England in 1980 of the Report of the Working Group on Inequalities in Health, better known as the Black Report after the chair of the working group, Sir Douglas Black, then chief scientist of the U.K. Department of Health and subsequently president of the Royal College of Physicians. The report showed that occupational class differences in health were greater than differences by gender, race, or regional background and, most distressingly, had actually increased between 1949–1953 and

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Promoting Health: Intervention Strategies from Social and Behavioral Research 1970–1972 over the first quarter-century of existence of the British National Health Service. Nor did things improve between the early 1970s and 1980s (Marmot et al., 1987). During the 1980s and early 1990s, the British experience was replicated in other developed countries including Canada, where the introduction of national health insurance in the early 1970s had little effect on socioeconomic differences in health (Wilkins et al., 1989). Finally, adjustments for gross access to and utilization of medical care have contributed little or nothing to explaining socioeconomic and racial/ethnic differences in health in our and other data. However, we believe that the role of medical care in socioeconomic and racial/ethnic health differences deserves renewed examination and research. First, compared to whites, racial/ethnic minorities have lower levels of access to medical care in the United States (Blendon et al. 1989; Trevino et al. 1991). Second, higher incidence rates for racial/ethnic minorities do not fully account for the higher death rates (Schwartz et al. 1990). Later initial diagnosis of disease, comorbidity, delays in medical treatment, and disparities in the quality of care also play a role. There is growing evidence of large racial/ethnic differences in the quality of medical care. Many studies have found racial/ethnic differences in the receipt of therapeutic procedures for a broad range of conditions even after adjustment for insurance status and severity of disease (e.g., Wenneker and Epstein, 1989; Harris et al. 1997). These disparities exist even in contexts where differences in economic status and insurance coverage are minimized, for example, the Veterans Administration Health System (e.g., Whittle et al., 1993) and the Medicare program (e.g., McBean and Gornick, 1994). Recent studies document that these differences in medical treatment adversely affect the health of minority group members (Peterson et al., 1997; Hannan et al., 1999). Moreover, medical care appears to play a modest role in accounting for racial differences in mortality (Woolhandler et al., 1985; Schwartz et al., 1990), and other evidence suggests that medical care has a greater impact on the health status of vulnerable racial and low-SES groups than on their more advantaged counterparts (Williams, 1990). More generally, behind declining socioeconomic and racial/ethnic disparities in gross levels of access to and utilization of medical care may lie in persisting differences in access to more continuous care from a concerned and responsive provider, associated differences in access to and utilization of important standards of preventive care (e.g., blood pressure, prostate and colorectal screening, Pap smears, mammograms, and professional advice on health behaviors), and differences in the timeliness and appropriateness of access to state-of-the-art standards of therapeutic care. Thus, socioeconomic and racial/ethnic disparities in standards and appropriateness of medical care merit increased attention in research and policy.

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Promoting Health: Intervention Strategies from Social and Behavioral Research FIGURE 6 Total mortality, United States, 1900–1995. other major income support program in our country has been the earned income tax credit, but we know of no research on its effects and would certainly see such research as a high priority for the future. Investment in Public Goods and Infrastructure Limited data also indicate that efforts to improve the public goods and infrastructures of communities improve the health of their residents. Some research suggests that policy changes to improve neighborhoods can importantly enhance health. Dalgard and Tambs (1997) provide findings from a 10-year follow-up study of residents in five neighborhood types in Norway. This study found that residents in a poorly functioning neighborhood that had experienced dramatic change in its social environment over time reported improved mental health 10 years later. The improvements in the neighborhoods included a new public school, playground extension, establishment of a sports arena and park, organization of activities for adolescents by the sports association of the municipality, establishment of a shopping center with restaurants and a cinema, and a subway line extension into the neighborhood. This effect was not explained by selective migration. Similarly, an intervention in England for a poorly functioning neighborhood also had dramatic effects (Halpern, 1995). Over a 2-year period this intervention refurbished housing, with a special emphasis on making it

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Promoting Health: Intervention Strategies from Social and Behavioral Research safe and sheltered from strangers. Changes included improved traffic regulations, improved lighting and strengthening of windows, enclosure of gardens for apartments, closure of alleyways, and landscaping. In this project, residents were involved in the planning process. A 1-year follow-up study, conducted after the intervention had been in place, documented that the changes in the physical environment were associated with changes in the social environment and mental health as well. That is, the contact between neighbors had increased and neighbors reported more trust in each other. Levels of optimism and belief in the future had increased, and residents felt a stronger identification with their neighborhood. In addition, levels of anxiety and depression were significantly reduced among residents. This study reveals that improvement in the quality of life in a neighborhood can increase both the quality of social interaction or cohesion and health (see Paper Contribution I). The Case of Racial/Ethnic Disparities Racial/ethnic disparities in health should clearly be reduced by policies that reduce absolute and relative socioeconomic deprivation. However, they also need special approaches, obviously not aimed at changing race/ethnicity per se, but, rather, at changing the way race/ethnicity and associated racial/ethnic status are socially defined and constructed. Again, available evidence suggests there are reduced racial/ethnic disparities in health. Mullings (1989) has suggested that the civil rights movement, for example, had important positive effects on black health. By reducing occupational and educational segregation, it improved the SES of at least a segment of the black population and also influenced public policy to make health care accessible to larger numbers of people. Consistent with this hypothesis, one study found that between 1968 and 1978, blacks experienced a larger decline in mortality rates (on both a percentage and absolute basis) than whites (Cooper et al., 1981). CONCLUSION We hope this paper has produced an appreciation that socioeconomic and racial/ethnic disparities in health are the product of a broad and complex system of social stratification that will continue to structure the experience of and exposure to virtually all behavioral and psychosocial risk factors to health, hence producing large, persistent, and even increasing socioeconomic and racial/ethnic disparities in health. These health disparities largely explain why the United States increasingly lags behind other developed and even less developed nations in levels of population health, with the most disadvantaged portions of our population characterized by levels of population health comparable to some of the least developed nations in the world. Socioeconomic and racial/ethnic disadvantages affect almost all forms of disease; almost all behavioral, psychosocial, and environmental risk factors pro-

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Promoting Health: Intervention Strategies from Social and Behavioral Research ducing these diseases; and also access to the most appropriate and effective forms of medical care. These effects are persistent over time. Thus, as the major public health problems of society and the risk factors producing them change, they still will be more incident and prevalent among lower socioeconomic classes. Thus, intervening in or changing one or a few major risk factors for health (including inadequate medical care) can have only a limited effect on socioeconomic and racial/ethnic disparities in health, though this effect is clearly enhanced if interventions or changes are attentive to the broader social forces that produce these disparities. The greatest past accomplishments and future potential for reducing socioeconomic and racial/ethnic disparities in health and improving overall population health involve improving socioeconomic status and reducing invidious racial/ethnic distinctions themselves, especially among the more disadvantaged portions of the population. Thus, economic growth and development and progress toward greater racial/ethnic equality have had and can have dramatic effects on individual and population health, especially if these changes impact the more disadvantaged socioeconomic and racial/ethnic groups in our society. REFERENCES Adler, N.E., Boyce, T., Chesney, M.A., Cohen, S., Folkman, S., Kahn, R.L., and Syme, S.L. ( 1994). Socioeconomic status and health: The challenge of the gradient. American Psychologist, 49(1), 15–24. Adler, N.E., Boyce, T., Chesney, M.A., Folkman, S., and Syme, S.L. ( 1993). Socioeconomic inequalities in health: No easy solution. Journal of the American Medical Association, 269, 3140–3145. Amaro, H., Russo, N.F., and Johnson, J. ( 1987). Family and work predictors of psychological well-being among Hispanic women professionals. Psychology of Women Quarterly, 11, 505–521. Arno, P., and House, J.S. (in progress). Can socioeconomic policy improve population health and reduce social disparities in health: The case of Social Security. Backlund, E., Sorlie, P.D., and Johnson, N.J. ( 1996). The shape of the relationship between income and mortality in the United States. AEP, 6, 12–20. Barker, D.J.P., and Osmond, C. ( 1986). Infant mortality, childhood nutrition and ischaemic heart disease in England and Wales. Lancet, 1, 1077–1081. Ben-Shlomo, Y., White, I.R., and Marmot, M. ( 1996). Does the variation in the socioeconomic characteristics of an area affect mortality? British Medical Journal, 312, 1013–1014. Berkman, L.F., and Breslow, L. ( 1983). Health and Ways of Living. New York: Oxford University Press. Blane, D., Hart, C.L., Smith, G.D., Gillis, C.R., Hole, D.J., and Hawthorne, V.M. ( 1996). Association of cardiovascular disease risk factors with socioeconomic position during childhood and during adulthood. British Medical Journal, 313(7070), 1434–1438. Blau, P., and Duncan, O.D. ( 1967). The American Occupational Structure. New York: Wiley.

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