The Social Determinants of Chronic Disease

      This review article addresses the concept of the social determinants of health (SDH), selected theories, and its application in studies of chronic disease. Once ignored or regarded only as distant or secondary influences on health and disease, social determinants have been increasingly acknowledged as fundamental causes of health afflictions. For the purposes of this discussion, SDH refers to SDH variables directly relevant to chronic diseases and, in some circumstances, obesity, in the research agenda of the Mid-South Transdisciplinary Collaborative Center for Health Disparities Research. The health effects of SDH are initially discussed with respect to smoking and the social gradient in mortality. Next, four leading SDH theories—life course, fundamental cause, social capital, and health lifestyle theory—are reviewed with supporting studies. The article concludes with an examination of neighborhood disadvantage, social networks, and perceived discrimination in SDH research.
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      1. WHO. Rio Political Declaration at the World Conference on Social Determinants of Health; October 19–21, 2011; Rio de Janeiro, Brazil.

        • Solar O.
        • Irwin A.
        A conceptual framework for action on the social determinants of health.
        Social Determinants of Health Discussion Paper 2 (Policy and Practice). WHO, Geneva2010
        • National Center for Health Statistics
        Health United States 2015.
        U.S. Government Printing Office, Washington, DC2016
        • Cockerham W.C.
        Medical Sociology.
        13th ed. Routledge, New York2016
        • Link B.G.
        • Phelan J.
        Social conditions as fundamental causes of diseases.
        J Health Soc Behav. 1995; 36: 80-94
        • Phelan J.C.
        • Link B.G.
        Fundamental cause theory.
        in: Cockerham W.C. Medical Sociology on the Move: New Directions in Theory. Springer, Dordrecht2013: 105-126
        • Phelan J.C.
        • Link B.G.
        • Tehranifar P.
        Social conditions as fundamental causes of health inequalities: theory, evidence, and policy implications.
        J Health Soc Behav. 2010; 51: S28-S40
        • Cockerham W.C.
        Social Causes of Health and Disease. 2nd ed. Polity, Cambridge, UK2013
        • Holtz T.J.
        • Holmes S.
        • Stonington S.
        • Eisenberg L.
        Health is still social: Contemporary examples in the age of genome.
        PLoS Med. 2006; 3 (e4:19–e25)
      2. Woolf S.H. Laudan A. U.S. Health in International Perspective: Shorter Lives, Poorer Health. National Academies Press, Washington, DC2013
        • Frohlich K.L.
        • Abel T.
        Environmental justice and health practices: understanding how health inequities arise at the local level.
        Sociol Health Illn. 2014; 36: 199-212
        • Daw J.
        • Shanahan M.
        • Harris K.M.
        • Smolen A.
        • Haberstick B.
        • Boardman J.D.
        Genetic sensitivity to peer behaviors: 5HTTLPR, smoking, and alcohol consumption.
        J Health Soc Behav. 2013; 54: 92-108
        • Goodman A.
        • Joyce R.
        • Smith J.P.
        The long shadow cast by childhood physical and mental problems on adult life.
        Proc Natl Acad Soc U S A. 2011; 108: 6302-6337
        • Miech R.
        • Pampel F.
        • Kim J.
        • Rogers R.G.
        The enduring association between education and mortality: the role of widening and narrowing disparities.
        Am Sociol Rev. 2011; 76: 913-934
        • Montez J.K.
        • Anna Zajacova A.
        Explaining the widening education gap in mortality among U.S. white women.
        J Health Soc Behav. 2013; 54: 166-182
        • Sandoval J.
        • Esteller M.
        Cancer epigenomics: beyond genomics.
        Curr Opin Genet Dev. 2012; 22: 50-55
        • Yang Y.C.
        • McClintock M.K.
        • Kozloski M.
        • Li T.
        Social isolation and adult mortality: the role of chronic inflammation and sex differences.
        J Health Soc Behav. 2013; 54: 183-203
        • Carter B.D.
        • Christian A.C.
        • Fishkanich D.
        • et al.
        Smoking and mortality—beyond established causes.
        N Engl J Med. 2015; 372: 631-640
        • Hughes J.
        Learning to Smoke: Tobacco Use in the West.
        University of Chicago Press, Chicago2003
        • Pampel F.C.
        The persistence of educational differences in smoking.
        Soc Prob. 2009; 56: 526-542
        • Marmot M.G.
        • Shipley M.J.
        • Rose G.
        Inequalities in death-specific explanations of a general pattern.
        Lancet. 1984; 323: 1003-1006
        • Marmot M.
        • Smith G.D.
        • Stansfield S.
        • et al.
        Health inequalities among British civil servants: the Whitehall II study.
        Lancet. 1991; 337: 1387-1392
        • Wilkinson R.G.
        Unhealthy Societies.
        Routledge, London1996
        • Hill K.E.
        • Gleadle J.M.
        • Pulvirenti M.
        • et al.
        The social determinants of health for people with type 1 diabetes that progress to end-stage renal disease.
        Health Expect. 2015; 18: 2513-2521
        • Shariff-Marco S.
        • Yang J.
        • John E.M.
        • et al.
        Intersection of race/ethnicity and socioeconomic status in mortality after breast cancer.
        J Community Health. 2015; 40: 1287-1299
        • Tomayko E.J.
        • Flood T.L.
        • Tandis A.
        • Hanrahan L.P.
        Linking electronic health records with community-level data to understand childhood obesity risk.
        Pediatr Obes. 2015; 10: 436-441
        • Kim D.
        The associations between U.S. state and local social spending, income inequality, and individual all-cause and cause-specific mortality.
        Prev Med. 2015; 84: 62-68
        • Puckrein G.A.
        • Egan B.M.
        • Howard G.
        Social and medical determinants of cardiometabolic health.
        Ethn Dis. 2015; 25: 521-524
      3. Mortimer J. Shanahan M. Handbook of the Life Course. Kluwer/Plenum, New York2003
        • Phelan J.C.
        • Link B.G.
        • Diez-Rouz A.
        • Kawachi I.
        • Levin B.
        “Fundamental causes” of social inequalities in mortality: a test of the theory.
        J Health Soc Behav. 2004; 45: 265-285
        • Chang V.W.
        • Lauderdale D.S.
        Fundamental cause theory, technological innovation, and health disparities: the case of cholesterol in the era of statins.
        J Health Soc Behav. 2009; 50: 245-260
        • Lutfey K.
        • Freese J.
        Toward some fundamentals of fundamental causality: Socioeconomic status and health in the routine clinic visit for diabetes.
        Am J Sociol. 2005; 110: 1326-1372
        • Daw J.
        Explaining the persistence of health disparities: social stratification and the efficiency-equity trade-off in the kidney transplant system.
        Am J Sociol. 2015; 120: 1595-1640
        • Bourdieu P.
        The forms of capital.
        in: Kawachi I. Subramanian S. Kim D. The Handbook of Theory: Research for the Sociology of Education. Springer, New York1986: 51-62
        • Lin N.
        Social Capital: A Theory of Social Structure and Action.
        Cambridge University Press, Cambridge, UK2001
        • Putnam R.D.
        Bowling Alone: The Collapse and Revival of American Community.
        Simon & Schuster, New York2000
        • Sampson R.J.
        The neighborhood context of well-being.
        Perspect Biol Med. 2003; 46(3): S53-S64
        • Valente T.W.
        • Gallaher P.
        • Mouttapa M.
        Using social networks to understand and prevent substance use: a transdisciplinary perspective.
        Subst Use Misuse. 2004; 39: 1685-1712
        • Pentecost C.
        • Taket A.
        Understanding exercise uptake and adherence for people with chronic conditions: a new model demonstrating the importance of exercise identity, benefits of attending and support.
        Health Educ Res. 2011; 26: 908-922
        • Sherbourne C.D.
        • Hays R.D.
        • Ordway L.
        • DiMatteo M.R.
        • Kravitz R.L.
        Antecedents of adherence to medical recommendations: results from the Medical Outcomes Study.
        J Behav Med. 1992; 15: 447-468
        • Trivedi R.B.
        • Bryson C.L.
        • Udris E.
        • Au D.H.
        The influence of informal caregivers on adherence in COPD patients.
        Behav Med. 2012; 44: 66-72
        • Cicolini G.
        • Palma E.
        • Simonetta C.
        • Di Nicola M.
        Influence of family carers on haemodialyzed patients’ adherence to dietary and fluid restrictions: an observational study.
        J Adv Nurs. 2012; 68: 2410-2417
        • Rand C.S.
        • Nides M.
        • Cowles M.K.
        • Wise R.A.
        • Connett J.
        Long-term metered-dose inhaler adherence in a clinical trial. The Lung Health Study Research Group.
        Am J Respir Crit Care Med. 1995; 152: 580-588
        • Browning C.R.
        • Cagney K.A.
        Neighborhood structural disadvantage, collective efficacy, and self-rated physical health in an urban setting.
        J Health Soc Behav. 2002; 43: 383-399
        • Veenstra G.
        • Luginaah I.
        • Wakefield S.
        • Birch S.
        • Eyles J.
        • Elliott S.
        Who you know, where you live: social capital, neighbourhood and health.
        Soc Sci Med. 2005; 60: 2799-2818
        • Almedom A.M.
        Social capital and mental health: an interdisciplinary review of primary evidence.
        Soc Sci Med. 2005; 61: 943-964
        • Lindstrom M.
        Social capital and health-related behaviors.
        in: Kawachi I. Subramanian S.V. Kim D. Social Capital and Health. Springer, New York2008: 215-238
        • Lochner K.A.
        • Kawachi I.
        • Brennan R.T.
        • Buka S.L.
        Social capital and neighborhood mortality rates in Chicago.
        Soc Sci Med. 2003; 56: 1797-1805
        • Kim D.
        • Subramanian S.V.
        • Kawachi I.
        Social capital and physical health: a systematic review of the literature.
        in: Kawachi I. Subramanian S.V. Kim D. Social Capital and Health. Springer, New York2008: 139-190
        • Carpiano R.M.
        Actual or potential neighborhood resources for health: what can Bordieu offer for understanding mechanisms linking social capital to health?.
        in: Kawachi I. Subramanian S.V. Kim D. Social Capital and Health. Springer, New York2008: 83-93
        • Cockerham W.C.
        Health lifestyle theory and the convergence of agency and structure.
        J Health Soc Behav. 2005; 46: 51-67
        • Cockerham W.C.
        Bourdieu and an update of health lifestyle theory.
        in: Cockerham W.C. Medical Sociology on the Move: New Directions in Theory. Springer, Dordrecht2013: 127-154
        • Bauman Z.
        In Search of Politics.
        Stanford University Press, Stanford, CA1999
        • Bourdieu P.
        The Logic of Practice.
        Stanford University Press, Stanford, CA1990
        • Christensen V.T.
        • Carpiano R.M.
        Social class differences in BMI among Danish women: applying Cockerham’s health lifestyles approach and Bourdieu’s theory of lifestyle.
        Soc Sci Med. 2014; 112: 12-21
        • Stoller E.P.
        • Grzywacz
        • Quandt S.A.
        • et al.
        Calling the doctor: a qualitative study of patient-initiated physician consultation among rural older adults.
        J Aging Health. 2011; 23: 782-805
        • Cockerham W.C.
        The emerging crisis in American female longevity.
        Soc Curr. 2014; 1: 220-227
        • Ross C.E.
        Neighborhood disadvantage and adult depression.
        J Health Soc Behav. 2000; 41: 177-187
        • Ross C.E.
        • Mirowsky J.
        Neighborhood disadvantage, disorder, and health.
        J Health Soc Behav. 2001; 42: 258-276
        • Boardman J.D.
        • Finch B.K.
        • Ellison C.G.
        • Williams D.R.
        • Jackson J.S.
        Neighborhood disadvantage, stress, and drug use among adults.
        J Health Soc Behav. 2001; 42: 151-165
        • Kirby J.B.
        • Kaneda T.
        Neighborhood socioeconomic disadvantage and access to health care.
        J Health Soc Behav. 2005; 46: 15-31
        • Boardman J.D.
        • Saint Onge J.M.
        • Rogers R.G.
        • Denney J.T.
        Race differentials in obesity: the impact of place.
        J Health Soc Behav. 2005; 46: 229-243
        • Umberson D.
        • Montez J.
        Social relationships and health: a flashpoint for health policy.
        J Health Soc Behav. 2010; 51: S54-S66
        • Yang X.Y.
        • Kelly B.C.
        • Yang T.
        Together we have fun: native-place networks and sexual risk behaviours among Chinese male rural-urban migrants.
        Sociol Health Illn. 2016; 38: 559-575
        • Christakis N.A.
        • Fowler J.H.
        The spread of obesity in a large social network over 32 years.
        N Engl J Med. 2007; 357: 370-379
        • Christakos N.A.
        • Fowler J.H.
        The collective dynamics of smoking in a large social network.
        N Engl J Med. 2008; 358: 2249-2258
        • Williams D.R.
        • Wyatt R.
        Racial bias in health care and health: challenges and opportunities.
        JAMA. 2015; 314: 555-556
        • Williams D.R.
        • Leavell J.
        The social context of cardiovascular disease: challenges and opportunities for the Jackson Heart Study.
        Ethn Dis. 2012; 22: S1-S15
        • Sims M.
        • Diez-Roux A.V.
        • Dudley A.
        • et al.
        Perceived discrimination and hypertension among African Americans in the Jackson Heart Study.
        Am J Public Health. 2012; 102: S258-S265
        • Pavalko E.K.
        • Mossakowski K.N.
        • Hamilton V.J.
        Does perceived discrimination affect health? Longitudinal relationships between work discrimination and women’s physical and emotional health.
        J Health Soc Behav. 2003; 44: 18-33
        • Pachter L.M.
        • Coll C.G.
        Racism and child health: a review of the literature and future directions.
        J Dev Behav Pediatr. 2009; 30: 255-263
        • Mustillo S.
        • Krieger N.
        • Gunderson E.P.
        • et al.
        Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries: the CARDIA Study.
        Am J Public Health. 2004; 94: 2125-2131
        • Brondolo E.
        • Hausmann L.R.
        • Jhalani J.
        • et al.
        Dimensions of perceived racism and self-reported health: examination of racial/ethnic differences and potential mediators.
        Behav Med. 2011; 42: 14-28
        • Troxel W.M.
        • Matthews K.A.
        • Bromberger J.T.
        • Sutton-Tyrrell K.
        Chronic stress burden, discrimination, and subclinical carotid artery disease in African American and Caucasian women.
        Health Psychol. 2003; 22: 300-309
        • Gee G.C.
        • Spencer M.S.
        • Chen J.
        • Takeuchi D.
        A nationwide study of discrimination and chronic health conditions among Asian Americans.
        Am J Public Health. 2007; 97: 1275-1282
        • Van Houtven C.H.
        • Voils C.I.
        • Oddone E.Z.
        • et al.
        Perceived discrimination and reported delay of pharmacy prescriptions and medical tests.
        J Gen Intern Med. 2005; 20: 578-583
        • Burgess D.J.
        • Ding Y.M.
        • Hargreaves M.
        • van Ryn M.
        • Phelan S.
        The association between perceived discrimination and underutilization of needed medical and mental health care in a multi-ethnic community sample.
        J Health Care Poor Underserved. 2008; 19: 894-911
        • Trivedi A.N.
        • Ayanian J.Z.
        Perceived discrimination and use of preventive health services.
        J Gen Intern Med. 2006; 21: 553-558