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From page 138...
... 4 Social Risk Factors Among the greatest advances in elucidating the determinants of disease over the past two clecacles has been the identification of social anc3 psychological conditions that seem to influence morbiclity and mortality directly through physiological processes and indirectly via behavioral pathways. This chapter examines a set of sociopsychological factors for which substantial evidence exists for effects on health outcomes: socioeconomic status; social support anc3 networks; occupational stress, unemployment, anc3 retirement; social cohesion anc3 social capital, anc3 religious belief.
From page 139...
... followed 320,909 white and African American men for 16 years (Davey Smith et al., 1996a,b)
From page 140...
... The British Whitehall study of civil servants found that those in the lowest grades of employment were at highest risk for heart disease (Marmot et al., 1991) and that low levels of personal control in the work environment could explain much of this association (Bosma et al., 1997; Marmot et al., 1997~.
From page 141...
... Because causes of death that are purportedly "not amenable" to medical care show socioeconomic gradients similar to those of potentially treatable causes (Davey Smith et al., 1996a; Mackenbach et al., 1989) , it has been argued that differential access to healthcare programs anc3 services is not entirely responsible for socioeconomic differentials in health (Wilkinson, 19961.
From page 142...
... Psychosocial Context The most successful interventions of the many clinical trials incorporatec3 elements of social or organizational change to mollify incliviclual behavioral risk factors, such as alcohol anc3 tobacco consumption, diet, anc3 physical activity. Most behaviors are not randomly clistributec3 in the population, but rather are socially patterned anc3 often cluster with one another.
From page 143...
... , and between SES and biological risk factors (such as high blood pressure, high serum cholesterol and fibrinogen, and obesity; Davey Smith et al., 1996a,b; Kaplan and Keil, 1993; Lynch et al., 1997a; Marmot et al., 1991~. Statistical adjustment for such biological and behavioral risk factors yen' orally leads to attenuation of excess mortality among lower groups.
From page 144...
... . Results from an examination of site-specific cancer mortality (Davey Smith et al., 1991)
From page 145...
... , the lives people leacl, and the environments in which they live and work as adults. SOCIAL NETWORKS AND SOCIAL SUPPORT A social network is the web of social relationships that surround an incliviclual and the structural characteristics of that web.
From page 146...
... , social support in family relationships (Pierce et al., 1996) , social support anc3 personality (Pierce et al., 1997)
From page 147...
... Meta-analyses of the experimental literature support the hypothesis that perceived social isolation is associated with physiological adjustments, with the most reliable effects found for blood pressure, catecholamines, anc3 aspects of cellular anc3 humoral immune function (Seeman anc3 McEwen, 1996; Uchino et al., 1996~. In a study of carotid arthrosclerosis in micicile-agec3 men, higher intima media thickness of the carotid artery was found in those who lived alone than in those who cohabited even after controlling for age, health status, education, saturated fat consumption, anc3 smoking (Helminen et al., 19951.
From page 148...
... The count cleclinec3 more rapidly in men who reported lower "availability of attachments" at baseline. Although research on the physiological pathways that could link networks to health is just developing, researchers have clocumentec3 associations among social integration anc3 social support anc3 several physiological mechanisms related to health outcomes, including cardiovascular reactivity anc3 neuroenclocrine anc3 immune function (Seeman, 1996; Uchino et al., 1996~.
From page 149...
... The relative risks) associated with social isolation were not cen' Relative risk is the proportion of diseased people among those exposed to the relevant risk factor divided by the proportion of diseased people among those not exposed to the risk factor.
From page 150...
... Several other studies, both in the United States anc3 across the world, have replicated the basic obser' vation that social isolation increases the relative risk of mortality (Berkman, 1995; Berkman anc3 Kawachi, 2000; glazer, 1982; Cohen, 1988; House et al., 1982, 1988; Kaplan et al., 1988; Orth-Gomer anc3 Johnson, 1987; Pennix et al., 1997; Schoenbach et al., 1986; Seeman et al., 1988, 1993, 1996; Sugisawa et al., 1994; Welin et al., 19851. Powerful epidemiologic evidence consistently supports the notion that social ties, especially intimate ties anc3 emotional support proviclec3 by them, promote increased survival anc3 better prognosis among people with serious cardiovascular disease (Berkman et al., 1992; Case et al., 1992; Krumholz et al., 1998; Orth-Gomer et al., 1988; Oxman et al., 1995; Ruberman et al., 1984; Williams et al., 19921.
From page 151...
... One study of older adults in long~term marriages, for example, showed that 30 minutes of conflict discussion was associated with changes in cortisol, acirenocortico' tropic hormone, anc3 norepinephrine in women, but not in men (Kiecolt' Glaser et al., 1997~. Other studies linked marital conflict anc3 high blood pressure (Ewart et al., 1991)
From page 152...
... Studies published in the past 5 years bolster the importance of job control (for example, Bosma et al., 1997, 1998; Johnson et al., 1996; North et al., 1996; Theorell et al., 19981. A recent population-basec3 case/control study found that low job control was associated with incidence of first MI among employed Swedish men 45-64 years old, although the association was somewhat weakened by adjustment for social class (blue- or white-collar status; Theorell et al., 1998~.
From page 153...
... Effort/rewarc3 imbalance anc3 low job control were inclepenclent predictors of incident coronary heart disease among British civil servants in models acJjustec3 for age, employment gracle, negative affectivity, anc3 coronary risk profile (Bosma et al., 1998~. Relative risk ratios for high-effort anc3 low-rewarc3 conditions ranged from 2.59 to 3.63, clepencling on sex anc3 specific coronary end point.
From page 154...
... Baseline health status probably should be upciatec3 in such studies or, at a minimum, supplementec3 with reports of illness-relatec3 reasons for not working. As cliscussec3 for SES, the causation-versus-selection question is raised here as well; it is not clear whether unemployment causes excess mortality or whether background variables (such as social class and poor pre-existing health)
From page 155...
... Evidence on the impact of unemployment on health behaviors is mixed. Longitudinal data from the British Regional Heart Study (Morris et al., 1992, 1994)
From page 156...
... The increase was greater among those with increases in cardiovascular risk factors, particularly weight and blood pressure. However, no significant differential trencis over time were seen for weight, blood pressure, or blood glucose.
From page 157...
... tend to show some benefits of retirement, primarily in the psychological domain anc3 in health behaviors. A study of older steelworkers forced to retire early because of downsizing clic3 not show any adverse effects on their health (Gall et al., 1997; Gillanclers et al., 1991)
From page 158...
... be' tween income inequality, as measured by the Gini coefficient, anc3 life expectancy. The Gini coefficient is the most widely used measure of in' come distribution anc3 theoretically ranges from 0 (perfect equality)
From page 159...
... Income inequality was associated not only with higher total mortality but also with infant mortality anc3 rates of death from coronary heart disease, can' cer, anc3 homicide. The findings persisted after controlling for urban rural proportion anc3 for such health behavior variables as cigarette~smoking rates.
From page 160...
... States with the highest income inequality (as measured by the proportion of total household income received by the less well-off 50%) spent a smaller proportion of their budgets on education anc3 showed poorer educational outcomes, ranging from worse reacling anc3 mathematics proficiency to higher high school dropout rates.
From page 161...
... Race and Discrimination Although whites anc3 African Americans experienced substantial im' provements in life expectancy at all ages throughout the 20th century, substantial gaps remain in life expectancy, morbidity, anc3 functional sta' tus. The data suggest a temporal lag in life expectancies between the 2 groups in the United States.
From page 162...
... Krieger anc3 Sidney (1996) investigated the relationship between selfreportec3 racial discrimination anc3 blood pressure among 4086 African American anc3 white 25-34-year-olc3 participants in the Coronary Artery Risk Development in Young Adults study, a prospective, multisite, community-basec3 investigation.
From page 163...
... Degree of residential segregation was assessed with a widely used index, the percentage of African Americans who would need to relocate to make the ratio of African Americans to whites in every neighborhood the same as that for the city as a whole. Relative political power was clefinec3 as the ratio of the proportion of African American representatives on the city council to the proportion of the voting-age population that was African American.
From page 164...
... Level of distrust was strikingly correlated with age~acJjustec3 mortality (R = 0.79, P< .00011. Lowerlevels of trust were associated with higher rates of most major causes of death, including coronary heart disease, cancer, cerebrovascular disease, unin' tensional injury, anc3 infant mortality.
From page 165...
... Finally, neighborhood social capital could influence health through direct psychosocial pathways by providing social support anc3 acting as the source of self-esteem anc3 mutual respect, for example. Variations in the availability of psychosocial resources at the community level might explain the anomalous finding that inclivicluals with few social ties but who reside in socially cohesive communities such as East Boston (Seeman et al.,1993)
From page 166...
... Psychosomatic Medicine, 57, 213-225. Anderson, R.T., Sorlie, P., Backlund, E., Johnson, N., and Kaplan, G.A.
From page 167...
... (1997~. Low job control and risk of coronary heart disease in Whitehall II (prospective cohort)
From page 168...
... American Journal of Public Health, 86, 497-504. Davey Smith, G., Shipley, Ad., and Rose, G
From page 169...
... American Journal of Epidemiology, 129, 919933. Ferrie, J., Shipley, M., Marmot, M., Stansfeld, S., and Davey Smith, G
From page 170...
... American Journal of Community Psychology, 20, 333-347. House, J., Robbins, C., and Metzner, H
From page 171...
... . Social capital, income inequality, and mortality.
From page 172...
... (1990~. Racial and gender discrimination: Risk factors for high blood pressure?
From page 173...
... (1997~. Contribution of job control and other risk factors to social variations in coronary heart disease incidence.
From page 174...
... British Medical Journal, 294, 86-90. National Center for Health Statistics.
From page 175...
... (1993~. Lack of social support and incidence of coronary heart disease in middle-aged Swedish men.
From page 176...
... (1999~. Aggregation and the measurement of income inequality: Effects on morbidity.
From page 177...
... (1993~. Increasing inequality in coronary heart disease mortality in relation to educational achievement profiles of places of residence, United States, 1962 to 1987.
From page 178...
... (1992~. Social networks as predictors of ischemic heart disease, cancer, stroke, and hypertension: incidence, survival and mortality.
From page 179...
... The social context with the most immediate effects on disease management anc3 with the greatest implications for intervention is the family, broadly clefinec3 (Campbell, 1986; Campbell anc3 Patterson, 1995; Fisher et al., 19981. However, the ecologic perspective also emphasizes the importance of or' ganizations, communities, anc3 society as a whole.
From page 180...
... American Journal of Preventive Medicine, 9, 27-31. Israel, B.A., Cummings, K.M., Dignan, M.B., Heaney, C.A., Perales, D.P., Simons-Morton, B.G., and Zimmerman, M.A.
From page 181...
... Health Education Quarterly, 19, 18. Stokols, D


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