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标题：Life-Course Accumulation of Neighborhood Disadvantage and Allostatic Load: Empirical Integration of Three Social Determinants of Health Frameworks
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作者：Per E. Gustafsson ; Miguel San Sebastian ; Urban Janlert 等
期刊名称：American journal of public health
印刷版ISSN：0090-0036
出版年度：2014
卷号：104
期号：5
页码：904-910
DOI：10.2105/AJPH.2013.301707
语种：English
出版社：American Public Health Association
摘要：Objectives. We examined if the accumulation of neighborhood disadvantages from adolescence to mid-adulthood were related to allostatic load, a measure of cumulative biological risk, in mid-adulthood, and explored whether this association was similar in women and men. Methods. Data were from the participants in the Northern Swedish Cohort (analytical n = 818) at ages 16, 21, 30, and 43 years in 1981, 1986, 1995, and 2008. Personal living conditions were self-reported at each wave. At age 43 years, 12 biological markers were measured to operationalize allostatic load. Registered data for all residents in the cohort participants’ neighborhoods at each wave were used to construct a cumulative measure of neighborhood disadvantage. Associations were examined in ordinary least-squares regression models. Results. We found that cumulative neighborhood disadvantage between ages 16 and 43 years was related to higher allostatic load at age 43 years after adjusting for personal living conditions in the total sample (B = 0.11; P = .004) and in men (B = 0.16; P = .004), but not in women (B = 0.07; P = .248). Conclusions. Our findings suggested that neighborhood disadvantage acted cumulatively over the life course on biological wear and tear, and exemplified the gains of integrating social determinants of health frameworks. Different frameworks relevant to social determinants of health have been introduced, developed, and applied to research during the last 2 decades. We specifically aimed to empirically integrate the allostatic load, 1 neighborhoods and health, 2 and life-course epidemiology 3 frameworks by examining whether the life-course accumulation of neighborhood disadvantage was related to allostatic load in mid-adulthood. The allostatic load model 4,5 was developed within the stress physiology field and was introduced as a general framework for the cumulative “wear and tear” the body eventually experiences across multiple interrelated physiological systems because of repeated stressor exposures during the life course. Allostatic load (or cumulative biological risk) has been proposed as a biological link that explains socioeconomic disparities in morbidity and mortality 6,7 ; empirical studies have demonstrated that allostatic load is patterned by social determinants (e.g., ethnicity, education, and income) 8–11 and prospectively predicts mortality as well as cognitive and physical decline. 12–14 Studying the importance of the area of residence—defined, for example, by parishes, wards, or neighborhoods—for health represents a more contextual perspective on social determinants of health. For example, socioeconomic status aggregated at the neighborhood level is related to cardiovascular health beyond individual-level socioeconomic conditions. 2,15 Such effects have been attributed to several possible pathways, including (1) indirect-cognitive paths, where the effects are mediated by conscious responses such as health-damaging behaviors, and (2) direct-contextual paths, which include differential chronic stressor exposure and the potential development of allostatic load. 16 Cross-sectional studies in recent years have demonstrated that various neighborhood characteristics, such as socioeconomic disadvantages, 17 poverty, 11 lack of affluence, 18 and perceived neighborhood conditions, 19 are related to allostatic load. However, most studies within the field use cross-sectional or short-term prospective designs 20,21 ; conceptual and empirical elaborations of how social context affects health in the long term are lacking. 21 However, such a long-term temporal perspective emphasizes life-course epidemiology, which focuses on how and when exposures over the life course affect adult health outcomes, a question that is guided by conceptual life-course models. 3 The cumulative risk model, which posits that the most important aspect for health effects is the accumulation of exposures across the life course, is the model with the most consistent empirical support (e.g., socioeconomic disadvantages and cardiovascular outcomes). 22 Although the few recent register-based studies on area effects on health over the life course found only a small proportion of variance in adult morbidity and mortality to be attributable to the area of residence at specific life-course periods, 23 mortality risk clustered at the area of residence seemed to accumulate over the life course, corresponding to a cumulative risk life-course model. 24 The cumulative risk model is also the model that most closely corresponds to the allostatic load framework, which emphasizes the gradual accumulation of physiological dysregulation over the life course. 6 Empirical studies demonstrated that the life-course accumulation of individual socioeconomic disadvantages and of adversity from childhood or adolescence to mid-adulthood were related to allostatic load. 25–27 In summary, despite the unique contributions of research on the social determinants of health offered by allostatic load, neighborhoods and health, and the life-course epidemiology frameworks, empirical efforts to integrate them are at an early stage. To advance this task, the cumulative risk life-course model appears to be a promising focal point. The present 27-year prospective cohort study specifically aimed to examine whether socioeconomic disadvantages of the residence neighborhood at 4 time points during the life course were cumulatively related to allostatic load in mid-adulthood, when taking the life-course accumulation of disadvantageous personal living conditions into account. Previous research hypothesized that women were more embedded in their communities, and because of this, could be more exposed to neighborhoods stressors and health effects. 28 Therefore, our secondary aim explored this cumulative effect on allostatic load separately in women and men.