Poor Oral Health and Exposure to

The term social determinants of health (SDOH) is often used to refer to any nonmedical factors
influencing health, including healthȬrelated knowledge, attitudes, beliefs, or behaviors (e.g.,
smoking); however, SDOH also include “upstream” factors, such as social disadvantage, risk
exposure, and social inequities that play a fundamental causal role in poor health outcomes—
and thus represent important opportunities for improving health and reducing health
disparities. This paper describes and categorizes three types of approaches used to examine
upstream SDOH. Social disadvantage approaches focus on the link between health and
neighborhood conditions, working conditions, education, income and wealth, and
race/ethnicity and racism; a potential causal link is the role of stress related to coping with these
factors. Life course approaches focus on the link between health and critical or sensitive
periods in exposure to risk (adverse childhood experiences, intergenerational transfer of
advantage) as well as cumulative exposures; the potential causal link here may derive from the
effect of social status on the regulation of genes controlling physiologic functions (e.g., immune
functioning).ȱȱHealth equity approaches consider the link between health and social inequities
stemming from socioȬdemographic factors, such as class, immigration status, gender, sexual
orientation, and disability status; social capital can serve to moderate or mediate the effects of
these factors. The paper identifies several challenges to understanding upstream SDOH,
including the long and complex causal pathways linking these factors with health, multiple
intervening factors, limited ability to study these factors using randomized experiments, singleȬ
diseaseȬfocused research funding, and limited understanding of community buffers that can
mitigate the effects of SDOH.ȱȱ Poor Oral Health and Exposure to Adverse Childhood Experiences Essay
Social determinants of health (SDOH) are the conditions under which people are born, grow,
live, work, and age (Commission on Social Determinants of Health, 2008).ȱȱThe term is often
used to refer broadly to any nonmedical factors influencing health, including healthȬrelated
knowledge, attitudes, beliefs, or behaviors (e.g., smoking).ȱȱSDOH have a direct impact on the
health of individuals and populations; they also help structure lifestyle choices and behaviors,
which interact to produce health or disease. At the same time, SDOH are shaped by public
policy and thus, in theory, are modifiable.
As the field of SDOH grows, there is increasing emphasis on understanding and addressing the
fundamental causes, or upstream factors, of poor health and inequities.ȱȱUpstream SDOH refers
to the macro factors that comprise socialȬstructural influences on health and health systems,
government policies, and the social, physical, economic and environmental factors that
determine health.ȱȱȱWhile upstream concepts may intuitively make sense, the causal pathways
linking these determinants with health are typically long and complex, and often involve
multiple intervening factors along the way (Link and Phelan, 1995).ȱȱThis complexity makes it a
challenge to study, and, ultimately, to address, the fundamental upstream causes.
To better understand the upstream SDOH, we provide here a summary of the main categories
or theoretical approaches for understanding SDOH.ȱȱThis document is not meant to be a
comprehensive or exhaustive examination of every SDOH framework, but is intended to review
some of the more wellȬknown frameworks for addressing SDOH in research, policy, and
practice.ȱȱȱWe emphasize approaches where there is strong evidence of a link between SDOH
and health and promising leverage points for improving individual and population health
(socioȬpolitical interventions to improve populationȬlevel health).ȱȱȱWe also provide examples at
the end of this document of SDOH frameworks put forth by national and international health
Theoretical Approaches to SDOHȱȱ
Social disadvantage approach and healthȱȱ
Substantial research has linked educational attainment, reading level, income (U.S.), and
occupational grade (as used in Europe) with health outcomes throughout the life course.
Greater social disadvantage is associated with poorer health, and there appears to be a “doseȬ
response” relationship or stepwise/incremental gradient connecting social disadvantage to
poorer health (Braveman and Gottlieb, 2014).ȱȱResearch is needed to clarify the underlying
pathways, and health outcomes could reflect the direct health benefits of having more economic
resources (e.g., healthier nutrition/food security, housing, neighborhood conditions),Poor Oral Health and Exposure to Adverse Childhood Experiences Essay
unmeasured socioeconomic factors, and/or associated psychological or behavioral factors (e.g.,
perceived control); however, reverse causation could be an alternative explanation.ȱȱȱThe theory
of fundamental causes outlines why the association between socioeconomic status and health
disparities has persisted over time, and postulates that those in low socioeconomic status
communities lack resources to protect and/or improve health (Phelan et al., 2010). Specifically,
this theory suggests that living conditions and socioeconomic status influence multiple diseases
through multiple risk factors and lack of access to resources to reduce risk, and that the effects
are reproduced over time (Flaskerud and DeLilly, 2012, Phelan et al., 2010).
x Neighborhood conditions:ȱȱNeighborhoods can influence health through physical
characteristics (air and water quality, exposures, access to parks), the availability and
quality of neighborhood services (transportation, schools, employment resources, housing),
and social relationships within a geographic community (mutual trust among neighbors has
been linked to lower homicide rates) (Williams and Collins, 2001, Braveman et al., 2011,
Diez Roux and Mair, 2010).ȱȱ
x Working conditions:ȱȱThe physical aspects of work (occupational health and safety) can
influence health by affecting an individual’s risk of musculoskeletal injuries and disorders,
sedentariness, and obesity and obesityȬrelated chronic conditions (diabetes, heart disease).
In addition, the physical conditions in which work is performed (ventilation, noise level) as
well as the psychosocial aspects (high demand with low control, perceived imbalance of
efforts and rewards) and social aspects (mutual support among coworkers) have all been
associated with health. EmploymentȬrelated earnings and workȬrelated benefits (medical
insurance, paid leave, schedule flexibility, workplace wellness programs, retirement
benefits, childȬȱand elderȬcare resources) shape the healthȬrelated decisions individuals
make for themselves and their families (Egerter et al., 2008).
x Education:ȱȱEducational attainment is linked with health in three interrelated ways.ȱȱFirst,
education has been linked to better health through individuals’ increased health knowledge
and healthy behaviors. The mechanism is likely explained in part by literacy (Berkman et al.,
2011, DeWalt and Hink, 2009). Second, education shapes employment opportunities, which
are major determinants of the economic resources that influence health. Third, education
can influence health through social and psychological factors, with greater education linked
to greater perceived personal control (which has been associated with better health and
healthy behaviors), higher social standing, and increased social support. The role of
educational quality and its supports – employment opportunities, prestige, social networks
that come with a degree from an elite university – may also impact health (Figure 1).
Figure 1: Interrelated pathways linking education to health
ȱȱȱȱȱȱȱSource: Braveman P, et al. 2011. Annu Rev Public Health. 32:381Ȭ98. Used with permission.
x Income and wealth:ȱȱEconomic resources reflect income (monetary earnings during a specified
time period) and wealth (accumulated material assets), but the latter is less frequently
measured in health studies. Racial/ethnic differences in income markedly underestimate
differences in wealth (Braveman et al., 2005). In addition, income loss due to poor health
(reverse causation) does not fully account for the association between income/wealth and
health (Muennig, 2008, Kawachi et al., 2010).ȱȱSeveral researchers have observed health
effects of income/wealth even after adjusting for relevant factors, but these associations may
also reflect the effects of educational attainment and quality, childhood SES, neighborhood
characteristics, working conditions, and subjective social status. Income inequality has often
been linked with health, possibly through eroding social cohesion/solidarity (Wilkinson and
Pickett, 2006), although a causal link has been debated (Kaufman and Cooper, 1999,
Muntaner, 1999, Cooper and Kaufman, 1999).ȱȱȱ
x Race/ethnicity and racism:ȱȱRacism refers to discriminatory actions and attitudes, as well as the
systemic constraints on individuals’ opportunities and resources based on their race or
ethnicity.ȱȱRacial residential segregation is an example of institutional racism that produces
and perpetuates social disadvantage in resourceȬchallenged neighborhoods, lowȬquality and
underȬresourced schools, and inadequate and unsafe housing. Racism also directly impacts
health through stress (chronic stress via microaggressions1) pathways (Szanton et al., 2012,
Williams and Mohammed, 2009).
x Potential Causal Link – Role of Stress:ȱȱThe impact of social disadvantage on health is often the
result of coping with the daily challenges of these interrelated factors and their impact on
stress. Recent evidence implicates chronic stress in the causal pathways by linking multiple
upstream social determinants with health through neuroendocrine, inflammatory, immune,
and/or vascular mechanisms.ȱȱThe accumulated strain from stressful experiences may
trigger the release of cortisol, cytokines, and other substances that can damage the immune
defenses, vital organs, and physiologic systems, leading to moreȬrapid onset or progression
of chronic illness (cardiovascular disease, accelerated aging) (Adler and Stewart, 2010).ȱȱ
Allostatic load, i.e., the biological “wearȬandȬtear” resulting from chronic exposure to social
and environmental stressors is a multicomponent construct of the physiologic regulatory
system in the periphery/body and brain (McEwen, 2002).Poor Oral Health and Exposure to Adverse Childhood Experiences Essay
Life course approach and health
A life course approach takes into account critical or sensitive periods in exposure to risk as well
as dynamics related to cumulative exposure. Three models of life course are described
(Berkman, 2009, Elder Jr et al., 2003). In the first model, there is a latency period in which early
childhood or even prenatal exposures shape subsequent outcomes that may or may not be
evident for years. In the second life course model, exposures throughout life have a cumulative
effect (e.g., tobacco use). In the third model, often called social trajectory, early exposures may
create opportunities or barriers to critical exposures in later life, which are themselves the
critical exposures linked to disease outcomes (e.g., education impacts jobs and jobȬrelated
exposures). Two areas of strong evidence for SDOH are (1) the impact of social (dis)advantage
over the life course from early childhood experiences to adult health and (2) the health of future
generations. Upstream social determinants influence health at each life stage (childhood health,
adult health, family health and wellȬbeing), with accumulating social (dis)advantage and health
(dis)advantage over time.
x Adverse childhood experiences (ACE):ȱȱA strong body of SDOH evidence considers the adverse
health effects of early childhood experiences (associated with family social disadvantage),
showing that early experiences affect children’s cognitive, behavioral, and physical
development, which in turn, predict current and future health. Biologic changes due to
adverse socioeconomic conditions in infancy and toddler years appear to become
“embedded” in children’s bodies, determining their developmental capacity (Hertzman,
1999). Longitudinal studies (that follow individuals from early childhood into young
adulthood) have linked childhood developmental outcomes with subsequent educational
attainment (which is associated with adult health). However, pathways from ACE can be

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1 Microaggressions are brief and commonplace daily verbal, behavioral, or environmental indignities,
whether intentional or unintentional, that communicate hostile, derogatory, or negative racial slights and
insults toward people of color.


shaped by interventions. HighȬquality early childhood development interventions (e.g.,
First5LA initiatives, Head Start) ameliorate the effects of social disadvantage on children’s
development (Karoly et al., 2006).
x The intergenerational transfer of advantage:ȱȱTwo decades of literature examine how differences
in social advantage influence health both over lifetimes and across generations (Braveman
and Barclay, 2009, Braveman et al., 2011). Children of socially disadvantaged parents are
less healthy and have more limited educational opportunities, both of which reduce their
chances for good health and social advantage in adulthood. New research on geneȬ
environment interactions suggests that the intergenerational transmission of social
advantage and health may be partially explained by epigenetic changes in gene expression2,
which in turn are passed on to subsequent generations (Kuzawa and Sweet, 2009).
x Potential Causal Link – Epigenetics:ȱȱAnimal studies suggest that social status can affect the
regulation of genes controlling physiologic functions (immune functioning). Educational
attainment, occupational class, work schedules, perceived stress, and intimate partner
violence have been linked with changes in telomere length. Telomeres are DNAȬprotein
complexes capping the ends of chromosomes, protecting them against damage. Telomere
shortening is considered a marker of cellular aging that is controlled by both genetic and
epigenetic factors.ȱȱ
Health equity approach and health
Similar to race and racism, social inequities that stem from socioȬdemographic (and often less
modifiable) factorsȱȬȱsuch as class, immigration status, gender, sexual orientation, and disability
statusȱȬȱalso impact health and health inequities.ȱȱOne example of how to conceptualize the
effect of these lessȬmodifiable factors on health comes from the Bay Area Regional Health
Inequities Initiative framework, which was developed by local public health departments in San
Francisco (see figure 6; better resolution http://barhii.org/framework/).ȱȱIn this framework, there
is an emphasis on considering “health in all policies,” which is a collaborative approach to
improving the health of all people by incorporating health considerations into decisionȬmaking
across sectors and policy areas (Rudolph et al., 2013).ȱȱInstitutional policies and regulations from
corporations and businesses, government agencies, schools, and nonȬprofit organizations can
exacerbate or improve social inequities through a population’s living conditions (e.g., physical,
social, economic/work, and service environments); institutional policies including tax policies,
housing segregation, student quotas, zoning policies, education policies, immigration policies,
and policies about marriage.ȱȱȱȱOne upstream approach to achieving health equity is to address
institutions and their influence over living conditions.Poor Oral Health and Exposure to Adverse Childhood Experiences Essay

2 Epigenetics refers to the heritable changes in gene expression (turn on/turn off) that do not involve
changes to the underlying DNA sequence, i.e., a change in phenotype without a change in genotype.
x Potential Moderator/Mediator – Social Capital:ȱȱWhile definitions vary, social capital refers in
general to the institutions, relationships, and norms that shape the quality and quantity of a
society’s social interactions. The concept of social capital can be deconstructed into bonding
(relationships between family members or good friends, which involve social support
and/or shared social identity), bridging (relationships between people who are more loosely
connected and have a distinct social identity, such as members of a sports club), and linking
components (relationships that are characterized by power differences, such as
employer/employee), as well as structural (participation in group activities) and cognitive
components (social cohesion, trust) (Uphoff et al., 2013). There is evidence that demonstrates
the relationship between different measures of social capital and health, and some evidence
that social capital mediates the relationship between income inequality and health (Kawachi
et al., 1997). One review found that bonding and bridging social capital, such as social
support, social cohesion in a neighborhood, close friends, and emotional support from
family members, can buffer some of the negative effects of poverty on health, and might
decrease the vulnerability of people with a lower position on the social ladder. However,
certain types of social capital might benefit the health only of those who have sufficient
economic capital to access sufficient social capital and it may harm the health of those who
are excluded from participation in the relevant networks (e.g., poor mothers are less healthy
in moreȬaffluent areas compared to lessȬaffluent areas) (Uphoff et al., 2013).
Governance and health
The World Health Organization Commission for Social Determinants of Health (WHO CSDH)
brought together a global evidence base of what could be done to reduce health inequities,
demonstrating that wellȬexecuted economic and social policy could improve health and health
equity (Commission on Social Determinants of Health, 2008, Friel and Marmot, 2011).ȱȱThey
found that marked health inequities exist between regions, between countries, and within
countries, and that reducing these inequities requires attending to the unfair distribution of
power, money and resources, and the conditions of everyday life.ȱȱOne review examined the
role of governance mechanisms and health outcomes in lowȬȱand middleȬincome countries
(Ciccone et al., 2014) and discovered that the association between governance mechanisms and
health varied (direct, modified, moderating, and mixed). The quality of government (e.g., rule
of law, government effectiveness, perceived level of corruption) was positively associated with
healthy life expectancy, life expectancy at birth, and selfȬreported health status, and negatively
associated with child and maternal mortality. Public spending on child mortality had a stronger
effect in reducing child mortality in countries with lower levels of corruption and high
institutional capacity.ȱȱHigher levels of democracy reduced the impact of unfavorable economic
and trade policies (detrimental effects associated with exports, multinational corporations,
international lending institutions) on infant mortality. Four mechanisms by which governance
might influence health in these countries are health system decentralization that enables
responsiveness to local needs and values; health policymaking that aligns and empowers
diverse stakeholders; enhanced community engagement; and strengthened social capital.ȱȱȱ
In general, the empirical literature linking governance to health is relatively sparse. Both
nationally and abroad, policies that lead to improvements in social conditions—such as housing
mobility policies, income supplements, early childhood academic achievement, and the Civil
Rights Movement/Act—also affect health (Williams et al., 2008).ȱȱ
Challenges and priorities
There are several challenges to studying upstream SDOH:
ƒ SDOH’s impacts on health often occur through complex relationships that play out over
long periods of time and involve multiple intermediate outcomes that are subject to “effect
modification” by characteristics of people and settings along the causal chain. For example,
neighborhood socioeconomic disadvantage and higher concentration of convenience stores
have been linked to tobacco use (Chuang et al., 2005) and lower availability of fresh
produce, which—combinedȱȱwith concentrated fastȬfood outlets and few recreational
opportunities—canȱȱlead to poorer nutrition and less physical activity (Cummins and
Macintyre, 2006, GordonȬLarsen et al., 2006). However, the health consequences of the
chronic diseases related to these conditions will not appear for decades, and longitudinal
studies are expensive.ȱȱȱȱ
ƒ The complex multifactorial causal pathways do not easily lend themselves to testing with
randomized experiments, and we have limited ability to measure upstream determinants,
given that current measures do not fully capture or tease out distinct effects of income,
wealth, education, and occupation.ȱȱWith some notable exceptions [e.g., adverse childhood
experiences in early life; moving to opportunity housing experiment (Robert J. Sampson,
2008); natural experimental conditions (Ludwig et al., 2011)], this challenge leads to a gap in
knowledge about when, where, and how to intervene to address social factors to improve
health and reduce health disparities.ȱȱȱ
ƒ Research funding focused on single diseases (as opposed to focusing on causal/contributory
factors with effects across multiple diseases) potentially puts SDOH research at a
ƒ There needs to be a recognition of buffers and community assets that can mitigate the effect
of unfavorable upstream SDOH, since not every individual or community exposed to
adversity develops disease and poor health. This is particularly important when engaging in
communityȬbased participatory research and other stakeholderȬengaged research initiatives
and in examining the impact of resilience.
Despite these challenges, there are several priority areas for SDOH research (Braveman et al.,
2011).Poor Oral Health and Exposure to Adverse Childhood Experiences Essay
1. Descriptive studies and monitoring for changes over time in the distribution of key upstream
social factors (income, wealth, education) across groups defined by race/ethnicity,
geography, gender, and their association with health outcomes in specific populations and
2. Longitudinal research, including studies to build publicȬuse databases with comprehensive
information on both social factors and health collected over multiple generations using a
range of methodological techniques – multiple regression, instrumental variables, matched
caseȬcontrol designs, and propensity score matching – to reduce bias and confounding due
to unmeasured variables.ȱȱȱ
3. Link knowledge to elucidate pathways and assess interventions, or build the knowledge base
incrementally by linking a series of distinct studies that examine specific segments of the
pathway connects A (upstream determinant) to Z (ultimate health outcome). Once the links
in the causal chain are documented, a similar incremental approach could be applied to
study the effectiveness of interventions, e.g., testing the effects of an upstream intervention
on an intermediate outcome with established links to health.ȱȱȱȱ
4. Test multidimensional interventions versus seeking a magic bullet. Knowledge of pathways can
point to promising or at least plausible approaches, but generally cannot indicate which
actions will be effective and efficient under different conditions; that knowledge can come
only from wellȬdesigned intervention research, including both randomized experiments
(when possible and appropriate) and nonrandomized studies with rigorous attention to
comparability and bias.
5. Expand research funding beyond single disease and/or biomedical factors exclusively.ȱȱThis would
also include extending the timeframe to evaluate programs or policies.
6. Develop political will to translate knowledge to action. This includes developing a workforce to
understand and address SDOH, as well as providing evidence to design social/health
policies and evaluating social policies impact on health and health equity.
ȱ ȱ
In this appendix, we briefly describe and illustrate institutions and frameworks examining
upstream SDOH.
World Health Organization – The WHO Commission for Social Determinants of Health (WHO
CSDH) conceptual framework (Figure 2) is grounded in established theoretical traditions
(material/structuralist theory, psychoȬsocial model, social production of health model, ecoȬsocial
theory) and assumes that health is a social phenomenon. The framework distinguishes
”structural determinants” that include all social and political mechanisms (governance, macroȬ
economic policy, social policy, public policy, and social and cultural values) that generate,
configure, and maintain socioeconomic position (social class, gender, or ethnicity) and
”intermediary determinants” including not only working and living conditions, but also
behavioral, psychosocial, and biological factors and the health care system per se. Interactions
between structural and intermediary determinants then result in differentiations (inequities) in
health and wellȬbeing.ȱȱEvidence to support the case for addressing SDOH is divided into 5
action areas and 9 themes. The action areas are (i) adopt better governance for health and
development; (ii) promote participation in policymaking and implementation; (iii) further
reorient the health sector towards reducing health inequities; (iv) strengthen global governance
and collaboration; and (v) monitor progress and increase accountability.ȱȱThe nine themes are
employment conditions, social exclusion, public health conditions, women and gender equity,
early childhood development, health systems, globalization, measurement and evidence, and
urbanization. (Commission on Social Determinants of Health, 2008). Poor Oral Health and Exposure to Adverse Childhood Experiences Essay

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