An extensive literature has linked education to health outcomes, including mortality, morbidity, health behaviors, and functional limitations. The quality of education also may be relevant to health, but it is more difficult to assess accurately. Race/ethnicity, another set of important variables with robust associations to health, is addressed in Chapter 5.Įducation is usually assessed by the use of two standard questions that ask about the number of years of schooling completed and the educational credentials gained. These variables are highlighted because of their robust associations with health status and their well-documented and reliable methods of measuring these variables, and because there are good reasons to believe that these variables interact with both behavioral as well as inherited characteristics to influence health. This chapter focuses on presenting the key research findings for a few selected social variables-SES, the psychosocial work environment, and social networks/ social support. Comprehensive surveys of current areas of research in the social determinants of health can be found in existing textbooks ( Marmot and Wilkinson, 2006 Berkman and Kawachi, 2000). These variables include SES, race/ethnicity, gender and sex roles, immigration status and acculturation, poverty and deprivation, social networks and social support, and the psychosocial work environment, in addition to aggregate characteristics of the social environments such as the distribution of income, social cohesion, social capital, and collective efficacy. In recent years, social scientists and social epidemiologists have turned their attention to a growing range of social and cultural variables as antecedents of health. THE INFLUENCE OF SOCIAL AND CULTURAL VARIABLES ON HEALTH: AN OVERVIEW OF PAST RESEARCH The contexts in which social and cultural variables operate to influence health outcomes are called, generically, the social and cultural environment. In short, the influence of social and cultural variables on health involves dimensions of both time (critical stages in the life course and the effects of cumulative exposure) as well as place (multiple levels of exposure). Furthermore, poverty may differentially and independently affect the health of an individual at different stages of the life course (e.g., in utero, during infancy and childhood, during pregnancy, or during old age). For example, the detrimental health impact of growing up in a poor family may be potentiated if that family also happens to reside in a disadvantaged community (where other families are poor) rather than in a middle-class community. Moreover, these different levels of influence may co-occur and interact with one another to produce health. Thus, for example, poverty can be conceptualized as an exposure influencing the health of individuals at different levels of organization-within families or within the neighborhoods in which individuals reside. It should be emphasized at the outset that the social determinants of health can be conceptualized as influencing health at multiple levels throughout the life course. The purpose of this chapter is to provide an overview of the social variables that have been researched as inputs to health (the so-called social determinants of health), as well as to describe approaches to their measurement and the empirical evidence linking each variable to health outcomes. For other kinds of variables-such as social networks and social support or job stress-evidence of their links to health has accumulated over the past 30 years. For some types of social variables, such as socioeconomic status (SES) or poverty, robust evidence of their links to health has existed since the beginning of official record keeping. In addition, a growing body of research has documented associations between social and cultural factors and health ( Berkman and Kawachi, 2000 Marmot and Wilkinson, 2006). Health is determined by several factors including genetic inheritance, personal behaviors, access to quality health care, and the general external environment (such as the quality of air, water, and housing conditions). DEFINING THE SOCIAL AND CULTURAL ENVIRONMENT
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