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      Environmental Health Disparities: A Framework Integrating Psychosocial and Environmental Concepts

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          Abstract

          Although it is often acknowledged that social and environmental factors interact to produce racial and ethnic environmental health disparities, it is still unclear how this occurs. Despite continued controversy, the environmental justice movement has provided some insight by suggesting that disadvantaged communities face greater likelihood of exposure to ambient hazards. The exposure–disease paradigm has long suggested that differential “vulnerability” may modify the effects of toxicants on biological systems. However, relatively little work has been done to specify whether racial and ethnic minorities may have greater vulnerability than do majority populations and, further, what these vulnerabilities may be. We suggest that psychosocial stress may be the vulnerability factor that links social conditions with environmental hazards. Psychosocial stress can lead to acute and chronic changes in the functioning of body systems (e.g., immune) and also lead directly to illness. In this article we present a multidisciplinary framework integrating these ideas. We also argue that residential segregation leads to differential experiences of community stress, exposure to pollutants, and access to community resources. When not counterbalanced by resources, stressors may lead to heightened vulnerability to environmental hazards.

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          Most cited references148

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          Racial Differences in Physical and Mental Health: Socio-economic Status, Stress and Discrimination.

          This article examines the extent to which racial differences in socio-economic status (SES), social class and acute and chronic indicators of perceived discrimination, as well as general measures of stress can account for black-white differences in self-reported measures of physical and mental health. The observed racial differences in health were markedly reduced when adjusted for education and especially income. However, both perceived discrimination and more traditional measures of stress are related to health and play an incremental role in accounting for differences between the races in health status. These findings underscore the need for research efforts to identify the complex ways in which economic and non-economic forms of discrimination relate to each other and combine with socio-economic position and other risk factors and resources to affect health.
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            Neighborhood of residence and incidence of coronary heart disease.

            Where a person lives is not usually thought of as an independent predictor of his or her health, although physical and social features of places of residence may affect health and health-related behavior. Using data from the Atherosclerosis Risk in Communities Study, we examined the relation between characteristics of neighborhoods and the incidence of coronary heart disease. Participants were 45 to 64 years of age at base line and were sampled from four study sites in the United States: Forsyth County, North Carolina; Jackson, Mississippi; the northwestern suburbs of Minneapolis; and Washington County, Maryland. As proxies for neighborhoods, we used block groups containing an average of 1000 people, as defined by the U.S. Census. We constructed a summary score for the socioeconomic environment of each neighborhood that included information about wealth and income, education, and occupation. During a median of 9.1 years of follow-up, 615 coronary events occurred in 13,009 participants. Residents of disadvantaged neighborhoods (those with lower summary scores) had a higher risk of disease than residents of advantaged neighborhoods, even after we controlled for personal income, education, and occupation. Hazard ratios for coronary events in the most disadvantaged group of neighborhoods as compared with the most advantaged group--adjusted for age, study site, and personal socioeconomic indicators--were 1.7 among whites (95 percent confidence interval, 1.3 to 2.3) and 1.4 among blacks (95 percent confidence interval, 0.9 to 2.0). Neighborhood and personal socioeconomic indicators contributed independently to the risk of disease. Hazard ratios for coronary heart disease among low-income persons living in the most disadvantaged neighborhoods, as compared with high-income persons in the most advantaged neighborhoods were 3.1 among whites (95 percent confidence interval, 2.1 to 4.8) and 2.5 among blacks (95 percent confidence interval, 1.4 to 4.5). These associations remained unchanged after adjustment for established risk factors for coronary heart disease. Even after controlling for personal income, education, and occupation, we found that living in a disadvantaged neighborhood is associated with an increased incidence of coronary heart disease.
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              Bringing context back into epidemiology: variables and fallacies in multilevel analysis.

              A large portion of current epidemiologic research is based on methodologic individualism: the notion that the distribution of health and disease in populations can be explained exclusively in terms of the characteristics of individuals. The present paper discusses the need to include group- or macro-level variables in epidemiologic studies, thus incorporating multiple levels of determination in the study of health outcomes. These types of analyses, which have been called contextual or multi-level analyses, challenge epidemiologists to develop theoretical models of disease causation that extend across levels and explain how group-level and individual-level variables interact in shaping health and disease. They also raise a series of methodological issues, including the need to select the appropriate contextual unit and contextual variables, to correctly specify the individual-level model, and, in some cases, to account for residual correlation between individuals within contexts. Despite its complexities, multilevel analysis holds potential for reemphasizing the role of macro-level variables in shaping health and disease in populations.
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                Author and article information

                Journal
                Environ Health Perspect
                Environmental Health Perspectives
                0091-6765
                December 2004
                16 August 2004
                : 112
                : 17
                : 1645-1653
                Affiliations
                1University of Michigan School of Public Health, Department of Health Behavior and Health Education, Ann Arbor, Michigan, USA
                2Office of Policy, Economics and Innovation, and Office of Children’s Health Protection, U.S. Environmental Protection Agency, Washington, DC, USA
                Author notes

                Address correspondence to G.C. Gee, University of Michigan School of Public Health, Department of Health Behavior and Health Education, 1420 Washington Heights, Room M5224, Ann Arbor, MI 48109-2029 USA. Telephone: (734) 615-7825. Fax: (734) 763-7379. E-mail: gilgee@ 123456umich.edu

                We thank M. Zimmerman and O. Nweke for their helpful comments with previous drafts of the manuscript.

                The views expressed in this document are those of the authors and do not represent official U.S. Environmental Protection Agency policy.

                The authors declare they have no competing financial interests.

                Article
                ehp0112-001645
                10.1289/ehp.7074
                1253653
                15579407
                55651557-ea21-44d4-86f4-ca214ab95e14
                This is an Open Access article: verbatim copying and redistribution of this article are permitted in all media for any purpose, provided this notice is preserved along with the article's original DOI.
                Categories
                Research
                Review

                Public health
                framework,race,stress,environmental justice,review,health disparities,psychosocial,environmental,ethnicity

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