HEA 608, Fall 2018 Rose Ewald

Building Causal Chains with Health Data

The physical and social environments are interrelated non-medical factors, known as the social

determinants of health.1-3 Differences in community design and unequal distribution of neighborhood

characteristics result in health disparities that disproportionately affect disadvantaged populations.1,3

Neighborhood attributes that affect physical activity rates include walkability, connectivity of sidewalks

and streets, road proximity, traffic safety, residential density, and recreational facilities.4 These features,

along with proximity to supermarkets, grocery stores, convenience stores, and fast food restaurants, are

highly correlated with risk factors for cardiovascular disease, such as hypertension, diabetes mellitus,

metabolic syndrome, and body mass index.4 Neighborhoods that lack parks and recreational facilities,

and that have an abundance of fast food and alcohol outlets and deteriorated housing, are associated

with problematic health outcomes.5,6

In addition to these factors in the built environment, disadvantaged communities frequently

have high income inequality, limited educational and economic opportunities, and less access to social

services and medical care.1,7-9 One’s level of education directly affects opportunities for employment and

therefore income, which in turn influence one’s access to and choice of housing, food, transportation,

health care, and leisure activities.1,2 The lack of opportunity for and access to—as well as the quality and

availability of—education and employment perpetuate and reinforce socioeconomic, racial, and ethnic

health disparities.1,7,9 Individual socioeconomic status is positively correlated with health across all racial

and ethnic groups and across all income levels, with the poorest health found among those with the

least education and income.1,2 Low income and minority populations are disproportionately affected by

hypertension,10 obesity,5,6 heart disease, and cancer.3

To explore the effect of the social determinants of health, I compared selected demographics

and health-related factors and outcomes for Franklin and Stanly counties in North Carolina, as shown in

the table. Franklin county is about 20 miles northeast of Raleigh and Stanly county is about 30 miles

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HEA 608, Fall 2018 Rose Ewald

northeast of Charlotte. In many respects, the counties were very similar. In 2010, Franklin county had a

population of 62,989 in 492 square miles and Stanly county had a population of 60,610 in 395 square

miles, with low population densities of 128 and 153 people per square mile, respectively. The total

population living in rural areas was 85.3% and 67.7% for Franklin and Stanly counties, respectively. In

contrast, North Carolina had a population density of 204.5 people per square mile with 33.9% living in

rural areas. The 2010 county population distributions by gender were similar and comparable to the

state distribution. The 2010 county distributions by age were also similar, but both counties had a deficit

of people aged 18 to 34 and a surplus of people aged 35 and over, compared to the state distribution. In

addition, the population with a disability in both counties was higher than for the state as a whole.

There were a few differences between the county demographics. In 2010, the population

distribution by race showed that Franklin county had 67.3% white, 25.8% African-American, and 6.9%

other races and Stanly county had 84.5% white, 10.5% African-American, and 5.0% other races, whereas

North Carolina had a population distribution of 69.2% white, 21.5% African-American, and 9.3% other

races. One of the most significant factors was the rate of population growth. Between 2000 and 2010,

the population in North Carolina increased by 18.5%, but the rate of growth in the counties was quite

different: 28.3% in Franklin county and 4.3% in Stanly county. Between 2010 and 2016, the rate of

growth slowed to 6.5% for the state, but again, the rate of growth in the counties was quite different:

8.1% in Franklin county and 1.9% in Stanly county.

The robust growth in population peaked at the same time as the economic downturn in 2008-

2010, and correlated with another important factor: a rapid spike in unemployment rates that crested in

January, 2010. From their highest point until December, 2016, the unemployment rates gradually

declined from 11.9% to 4.9% in Franklin county (https://fred.stlouisfed.org/series/NCFRAN9URN) and

from 14.6% to 4.5% in Stanly county (https://fred.stlouisfed.org/series/NCSTAN7URN), which mirrored

the decline in North Carolina from 12.0% to 4.8% (https://fred.stlouisfed.org/series/NCURN).

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HEA 608, Fall 2018 Rose Ewald

Comparison of Demographics and Health-Related Factors and Outcomes for the Period 2010-2016
Franklin County Stanley County North Carolina
General Population-Related Factors
Total 2010 Population1 62,989 60,610 9,940,828
1
Total Land Area in Square Miles 491.75 395.13 48,618.49
1
2010 Population Density/Square Mile 128.09 153.39 204.47
1
Total Population living in Rural Areas 51,719 85.3% 41,024 67.7% 3,233,727 33.9%
1
Total Population with a Disability 9,144 14.8% 9,390 15.9% 1,331,570 13.7%
2
Population Increase from 2000 to 2010 13,359 28.3% 2,485 4.3% 1,486,176 18.5%
3
Population Increase from 2010 to 2016 4,907 8.1% 1,166 1.9% 620,254 6.5%
1
Population by Gender and Age
Total 2010 Population 62,989 60,610 9,940,828
Male Population: 31,235 49.6% 30,158 49.8% 4,834,592 48.6%
Under 18 Years 7,514 24.1% 6,813 22.6% 1,167,074 24.1%
18 to 34 Years 6,540 20.9% 6,305 20.9% 1,134,173 23.5%
35 to 64 Years 13,010 41.7% 12,326 40.9% 1,900,414 39.3%
65 and Over 4,171 13.4% 4,714 15.6% 632,931 13.1%
Female Population: 31,754 50.4% 30,452 50.2% 5,106,236 51.4%
Under 18 Years 6,922 21.8% 6,467 21.2% 1,120,752 22.0%
18 to 34 Years 5,889 18.6% 5,936 19.5% 1,128,543 22.1%
35 to 64 Years 13,555 42.7% 12,158 39.9% 2,030,542 39.8%
65 and Over 5,388 17.0% 5,891 19.4% 826,399 16.2%
1
Population by Race
Total 2010 Population: 62,989 60,610 9,940,828
White Alone 42,412 67.3% 51,212 84.5% 6,882,915 69.2%
Black or African American Alone 16,230 25.8% 6,369 10.5% 2,137,131 21.5%
Other Races 4,347 6.9% 3,029 5.0% 920,782 9.3%
Social and Economic Factors
Education1
No High School Diploma, Age 25+ 7,256 16.8% 6,380 15.3% 914,827 13.7%
Associates Degree, Age 25+ 4,487 10.4% 4,528 10.8% 607,780 9.1%
Bachelor’s Degree or More, Age 25+ 8,805 20.4% 6,734 16.1% 1,940,435 29.0%
1
Income
Median Family Income $53,788 $55,209 $59,667
Per Capita Income $22,393 $22,103 $26,778
Families Earning over $75,000 5,617 34.3% 5,398 33.3% 974,675 38.8%
Insured and Uninsured Population
Total Uninsured Population4 8,588 13.9% 7,306 12.3% 1,290,195 13.2%
4
Uninsured Adults Aged 18 to 64 6,189 16.1% 5,222 14.9% 922,624 15.1%
1
Insured Population Receiving Medicaid 13,407 25.1% 11,117 21.4% 1,771,272 21.0%

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HEA 608, Fall 2018 Rose Ewald

Poverty-Related Factors
Population w/Income ≤ 200% FPL1 25,365 41.4% 23,540 40.2% 3,649,420 37.7%
Housing Costs Exceed 30% of Income1 7,340 31.0% 6,727 28.5% 1,157,673 30.3%
Households Receiving SNAP Benefits1 3,868 16.3% 3,619 15.3% 548,656 14.4%
Population Receiving SNAP Benefits5 10,897 17.1% 9,694 16.0% 1,610,504 16.0%
Food Insecure Pop. Assistance Ineligible6 9,930 20.0% 9,720 28.0% 1,801,940 27.0%
Physical and Environmental Factors
Recreation & Fitness Fac./100,000 Pop.7 4 6.6 15 24.8 1,122 11.8
Availability and Utilization of Health Care
Pop. in Health Prof. Shortage Area8 60,619 100% 60,585 100% 5,259,940 51.2%
Dentists/100,000 Population9 12 18.8 23 37.9 5,324 53.0
Primary Care Providers/100,000 Pop.10 11 17.5 26 42.9 7,955 80.0
Adults Aged 18+ w/No Regular Doctor11 11,975 27.3% 6,001 14.3% 1,790,298 24.5%
Preventable Hospital Events/1,000
327 63.4 499 64.7 46,407 49.0
Medicare Enrollees (Age-Adjusted)12
Retail Food Access
Fast Food Restaurants/100,000 Pop.7 28 46.9 50 82.5 7,688 80.6
Groceries, Supermarkets/100,000 Pop.7 8 13.2 14 23.1 1,923 20.2
SNAP-Authorized Stores/10,000 Pop.13 73 12.0 58 9.6 9,664 10.1
Modified Retail Food Environment Index14
Pop. w/No Food Outlets 0 0.0% 0 0.0% 28,606 0.3%
Pop. w/No Healthy Food Outlets 20,465 33.8% 12,875 21.2% 1,525,677 16.0%
Pop. w/Low Healthy Food Outlets 8,535 14.1% 16,812 27.8% 2,402,942 25.2%
Pop. w/Moderate Healthy Food Outlets 23,029 38.0% 30,898 51.0% 5,196,838 54.5%
Pop. w/High Healthy Food Outlets 8,590 14.1% 0 0.0% 381,420 4.0%
Health Behaviors
No Leisure Time Physical Activity15 13,113 27.4% 14,034 29.2% 1,752,076 23.4%
Ever Smoked 100 or More Cigarettes11 23,435 53.5% 22,546 53.9% 3,389,523 46.6%
Smokers w/Quit Attempt in Past Year11 8,213 76.0% 4,852 61.4% 965,312 62.3%
Regularly Smoke Cigarettes, 2012 Rate16 12,020 26.7% 11,797 27.0% 1,445,576 20.4%
Regularly Smoke Cigarettes, 2015 Rate17 8,020 15.6% 8,376 17.4% 1,514,713 19.0%
Health Outcomes
Diabetes, Aged 20+, Age Adjusted15 6,448 12.3% 5,547 10.4% 800,067 10.1%
Diabetes, Medicare Population18 2,025 30.4% 3,056 31.4% 337,918 28.4%
High Cholesterol, Aged 18+11 15,976 53.3% 14,410 54.2% 2,198,248 38.5%
High Cholesterol, Medicare Population18 3,063 45.9% 4,788 49.3% 550,256 46.3%
High Blood Pressure, Aged 18+17 16,966 33.0% 15,838 32.9% 2,854,038 35.8%
High Blood Pressure, Medicare Pop.18 4,080 61.2% 5,809 59.8% 689,562 58.0%
Heart Disease or Angina, Aged 18+11 1,520 3.5% 833 2.0% 323,236 4.4%
Heart Disease, Medicare Population18 1,503 22.5% 2,409 24.8% 284,805 24.0%

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HEA 608, Fall 2018 Rose Ewald

Overweight (BMI >25, ≤30), Aged 20+11 13,618 32.3% 16,560 41.3% 2,477,300 36.1%
15
Obesity (BMI>30), Aged 20+ 14,356 30.8% 13,767 30.0% 2,168,169 29.6%
19
Cancer Incidence/100,000 Population 1,816 470.4 1,879 479.1 267,539 464.6
19
Colorectal Cancer/100,000 Population 147 40.2 158 40.3 20,617 36.1
19
Lung Cancer/100,000 Population 291 73.1 293 70.9 38, 865 66.3
Average Annual Mortality Rate/100,000 Population, Age-Adjusted20
All Cancers 145 224.1 143 235.2 19,526 192.4
Colorectal Cancer 11 17.0 12 19.7 1,611 15.9
Lung Cancer 49 75.7 40 65.8 5,576 55.0
Heart Disease 120 185.5 177 291.2 18,276 180.1
Stroke 36 55.6 44 72.4 4,941 48.7
Data Sources:
1
US Census Bureau, American Community Survey. 2012-2016 (Five Year Estimates). Source geography: Tract
2
US Census Bureau, Decennial Census. 2000-2010. Source geography: Tract
3
NC Office of State Budget and Management, Standard Population Estimates, 2016 Certified County Population
Estimates. 2017. Source geography: County
4
US Census Bureau, Small Area Health Insurance Estimates. 2016. Source geography: County
5
US Census Bureau, Small Area Income & Poverty Estimates. 2015. Source geography: County
6
Feeding America. 2014. Source geography: County
7
US Census Bureau, County Business Patterns. Additional data analysis by CARES. 2016. Source geography: ZCTA
8
US DHHS, Health Resources and Services Administration, Health Resources and Services Administration. April
2016. Source geography: HPSA
9
US Department of Health & Human Services (DHHS), Health Resources and Services Administration, Area Health
Resource File. 2015. Source geography: County
10
US DHHS, Health Resources and Services Administration, Area Health Resource File. 2014. Source geography:
County
11
CDC, Behavioral Risk Factor Surveillance System (BRFSS). Additional data analysis by CARES. 2011-12. Source
geography: County
12
Dartmouth College Institute for Health Policy & Clinical Practice, Dartmouth Atlas of Health Care. 2014. Source
geography: County
13
US Department of Agriculture, Food and Nutrition Service, USDA - SNAP Retailer Locator. Additional data analysis
by CARES. 2017. Source geography: Tract
14
Centers for Disease Control and Prevention (CDC), Division of Nutrition, Physical Activity, and Obesity. 2011.
Source geography: Tract
15
CDC, National Center for Chronic Disease Prevention and Health Promotion. 2013. Source geography: County
16
CDC, BRFSS. Accessed via the Health Indicators Warehouse. US DHHS, Health Indicators Warehouse. 2006-2012.
Source geography: County (Age-Adjusted)
17
NC DHHS, North Carolina State Center for Health Statistics, BRFSS Survey Results: North Carolina. 2015. Source
geography: County
18
Centers for Medicare and Medicaid Services. 2015. Source geography: County
19
NC DHHS, North Carolina State Center for Health Statistics, Preliminary Cancer Incidence Rates by County for
Selected Sites, for 2012-2016, from the Central Cancer Registry. 2017. Source geography: County
20
NC DHHS, North Carolina State Center for Health Statistics, Vital Statistics Volume 2: Leading Causes of Death for
2016. 2012-2016. Source geography: County

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HEA 608, Fall 2018 Rose Ewald

These population-related factors drive social, economic, physical, and environmental factors in

communities.1-3 Risk factors for heart disease and cancer include smoking, poor diet, and inadequate

exercise, which are more frequently found in disadvantaged populations.3 The effect of these factors

may be seen in the health behaviors, health outcomes, and mortality rates in Franklin and Stanly

counties, as shown in the table. Compared to the rates for the state as a whole, both counties had

higher rates of obesity, diabetes, hypertension, hyperlipidemia, and colorectal and lung cancer, and

higher mortality rates for heart disease, stroke, and colorectal and lung cancer.

It should be noted that health outcomes in the table may be understated because 100% of the

populations in both Franklin and Stanly counties and 51.2% of the state population were in what is

known as a Health Professional Shortage Area. For every 100,000 people, North Carolina had 53.0

dentists and 80.0 primary care providers, but in Franklin and Stanly counties, there were just 18.8 and

37.9 dentists, and 17.5 and 42.9 primary care providers, respectively. Furthermore, in Franklin and

Stanly counties, 27.3% and 14.3% of adults aged 18 and over reported that they had no regular doctor

(versus 24.5% statewide), and preventable hospital events were reported at 63.4 and 64.7 per 1,000

Medicare enrollees, respectively (versus 49.0 per 1,000 Medicare enrollees statewide). Nevertheless,

some possible causal chains for the reported health outcome rates are discussed below.

Socioeconomic status (SES) is considered a fundamental cause of disease because it is an

indicator of resources (e.g., knowledge, money, power, and social support) that enable a person to avoid

health risks, gain access to treatment, and minimize disease consequences.2 Education in particular is

positively correlated with greater employment opportunities, higher rates of employment, higher

earning capacity, and more likelihood of health insurance and other health-related benefits.1 Greater

education also improves health literacy, increases healthy behaviors, and is strongly linked with health

outcomes.1 Of the respective populations aged 25 and over in Franklin and Stanly counties, 16.8% and

15.3% had no high school diploma (versus 13.7% statewide), 10.4% and 10.8% had an Associate’s degree

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HEA 608, Fall 2018 Rose Ewald

(versus 9.1% statewide), and 20.4% and 16.1% had a Bachelor’s degree or higher (versus 29.0%

statewide). The education levels in both counties were significantly below the state levels, and were

comparable for those with no high school diploma or with an Associate’s degree, but 25% more had

obtained a Bachelor’s degree or higher in Franklin county compared to Stanly county.

In both counties, the effect of lower education levels on earning capacity was reflected in

reported income levels. The median family income, per capita income, and percentage of families

earning over $75,000 per year were comparable for both counties, but significantly below the income

levels for the state as a whole. Statewide, 38.8% of families earned over $75,000 per year and 37.7% of

the population had income at or below 200% of the federal poverty level, but the respective rates were

34.3% and 41.4% for Franklin county, and 33.3% and 40.2% for Stanly county. The high rates of

unemployment at the time of the 2010 census undoubtedly exacerbated these factors. In addition,

although the percentages were similar for Stanly county and the state, a higher percentage of people in

Franklin county were uninsured (regardless of age) and a significantly higher percentage of the insured

population received Medicaid. One potential driver of the county-level differences could have been the

previously discussed rapid rate of population increase in Franklin county.

Morbidity and mortality patterns are generated by health-related resources, which are derived

from more general resources, such as knowledge, money, power, and social support.2 Even after

adjusting for differences in education, economic resources are positively correlated with and even

predictive of health outcomes.1 In addition to less education, fewer economic resources, and lack of

insurance coverage, when compared to statewide rates, Franklin and Stanly counties had higher rates of

diabetes and hyperlipidemia, as well as a much greater incidence and a higher average annual mortality

rate for colorectal and lung cancers. Rates of hypertension in both counties were lower than the state

rate for adults aged 18 and over but higher for older members of the population, which may reflect the

differences in population age distribution that were previously mentioned.

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HEA 608, Fall 2018 Rose Ewald

Although diabetes, hypertension, and hyperlipidemia are all risk factors for heart disease, rates

of heart disease for all ages in both counties appeared to be less than or comparable to state rates.

However, the greatest decreases in heart disease over recent decades have occurred among people

with higher SES,2 and this may account for the lower rates of heart disease in both counties, despite the

higher rates of predisposing factors. People with more economic resources are more likely to have

health insurance and private transportation,1 thus they can avail themselves of health care facilities in

adjacent metroplexes; residents in Franklin county can go to Raleigh and residents in Stanly county can

go to Concord or Charlotte. Lack of economic resources and a dearth of health care providers for the

disadvantaged populations in Franklin and Stanly counties would have allowed “invisible” conditions

such as diabetes, hypertension, hyperlipidemia, and cancer to occur without early diagnosis or adequate

treatment, thus contributing to higher mortality rates for heart disease, stroke, and cancer.

The fundamental effect of poverty on these health outcomes can be seen in the positive

correlation between SES and health; disadvantaged people have fewer resources and opportunities and

greater economic hardship, including lack of money for food and housing.11 Because more than 40% of

the residents in Franklin and Stanly counties had incomes at or below 200% of the federal poverty level,

it is unsurprising that housing costs exceeded 30% of income for 31.0% and 28.5% of the respective

populations in Franklin and Stanly counties, versus 30.3% of the statewide population. Similarly, in these

counties, 16.3% and 15.3% of the respective households and 17.1% and 16.0% of the respective

populations received SNAP benefits (versus 14.4% households and 16.0% of the population statewide).

In addition, the food insecure population that was ineligible for assistance was 20.0% and 28.0%

respectively in these counties, but 27.0% in the state.

These factors, combined with the mostly rural population demographics, were reflected in the

density of fast food restaurants and retail food stores. Statewide, there were 80.6 fast food restaurants

and 20.2 grocery stores and supermarkets for every 100,000 people, and 10.1 SNAP-authorized stores

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HEA 608, Fall 2018 Rose Ewald

for every 10,000 people. In Franklin county, there were 46.9 fast food restaurants and 13.2 grocery

stores and supermarkets for every 100,000 people, and 12.0 SNAP-authorized stores for every 10,000

people. In Stanly county, there were 82.5 fast food restaurants and 23.1 grocery stores and

supermarkets for every 100,000 people, but only 9.6 SNAP-authorized stores for every 10,000 people.

The availability of healthy foods reflected the availability of economic resources and the stratification of

incomes. The total population that had no or low healthy food outlets was 41.2% statewide, but 47.9%

and 49.0% respectively in Franklin and Stanley counties; the total population that had moderate or high

healthy food outlets was 58.5% statewide, but 52.1% and 51.0% respectively in the counties.

The density of unhealthy food outlets is correlated with overweight and obesity in both children

and adults,4,12 and this is exacerbated by lack of physical activity. Disparities in location and density of

recreational facilities contribute to decreased physical activity and increased weight in disadvantaged

populations.5,6,13 Obesity is strongly correlated with diabetes, hypertension, hyperlipidemia, and

cardiovascular disease, which are found in greater proportions among economically disadvantaged

communities.3-6,14 In North Carolina, there were 11.8 recreation and physical fitness facilities for every

100,000 people, but in Franklin county, there were 6.6 and in Stanly county, there were 24.8. At the

state level, 23.4% of residents reported no leisure time for physical activity, but 27.4% and 29.2% of

residents in Franklin and Stanly counties made that claim. Taken together, these factors account for the

high rates of overweight and obesity: 36.1% and 29.6% respectively at the state level, 32.3% and 30.8%

respectively in Franklin county, and 41.3% and 30.0% respectively in Stanly county.

Perhaps the most telling sign of economic disadvantage and low SES is the rate of tobacco use.

Socioeconomic status is a strong predictor of tobacco use, and smoking is so strongly associated with

poverty that it is considered a marker for economic deprivation.15 In rural communities, tobacco use is

considered more socially acceptable, and is more prevalent among adults and more readily available to

youth; these factors are also significant predictors of higher rates of use.16 There is a negative

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HEA 608, Fall 2018 Rose Ewald

correlation between nicotine dependence and SES, and disparities in smoking cessation rates have also

been correlated with SES: the smoking cessation rate among affluent people doubled between 1973 and

1996 while remaining virtually unchanged among disadvantaged people.15

In North Carolina, the pervasiveness of tobacco use was reflected in the 2012 rates of people

who reported ever smoking 100 or more cigarettes (46.6%) and those who had attempting to quit in the

past year (62.3%). In Franklin and Stanly counties, the rates of people who reported ever smoking 100 or

more cigarettes were significantly higher, at 53.5% and 53.9%, respectively, and the rates of those who

had attempted to quit in the past year were 76.0% and 61.4%, respectively. Statewide, the rate of those

who reported regularly smoking cigarettes decreased slightly from 20.4% in 2012 to 19.0% in 2015; in

Franklin and Stanly counties, the rates in 2012 were 26.7% and 27.0%, respectively, but these rates had

decreased significantly by 2015 to 15.6% and 17.4%, respectively. In addition, the prevalence of lung

cancer in Franklin and Stanly counties was 73.1 and 70.9 for every 100,000 people, versus 66.3 for every

100,000 people statewide, and the average annual mortality rate for lung cancer in Franklin and Stanly

counties was 75.7 and 65.8 for every 100,000 people, versus 55.0 for every 100,000 people at the state

level. Unfortunately, there is a 30-40 year lag between smoking prevalence and tobacco-related health

consequences,15 so despite the recent reductions in smoking rates in Franklin and Stanly counties, the

positive health effects will not be fully seen for decades.

In Franklin and Stanly counties, the complex and inter-related factors of the social determinants

of health had measurable effects on health behaviors, health outcomes, and mortality rates. Disparities

in education and income were fundamental drivers of differences in access to health care; poverty

limited access to affordable housing and healthy foods, which in turn influenced adiposity; and SES was

strongly and inversely correlated with tobacco use and its associated detrimental health effects. The

accumulation of these social and economic disadvantages was strongly associated with fewer healthy

choices, poorer health, greater incidence and prevalence of disease, and higher mortality rates.

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HEA 608, Fall 2018 Rose Ewald

References

1. Braveman PA, Egerter S, Williams DR. The Social Determinants of Health: Coming of Age. Annu
Rev Public Health. 2011;32(1):381-398. doi:10.1146/annurev-publhealth-031210-101218.
2. Link BG, Phelan J. Social Conditions as Fundamental Causes of Disease. J Health Soc Behav.
1995;35:80-94. doi:10.2307/2626958.
3. Phelan JC, Link BG, Tehranifar P. Social Conditions as Fundamental Causes of Health Inequalities:
Theory, Evidence, and Policy Implications. J Health Soc Behav. 2010;51(Supp):S28-S40.
doi:10.1177/0022146510383498.
4. Malambo P, Kengne AP, De Villiers A, Lambert E, V., Puoane T. Built Environment, Selected Risk
Factors and Major Cardiovascular Disease Outcomes: A Systematic Review. PLOS ONE.
2016;11(11):e0166846. doi:10.1371/journal.pone.0166846.
5. Cohen DA, Inagami S, Finch B. The Built Environment and Collective Efficacy. Health Place.
2008;14(2):198-208. doi:10.1016/j.healthplace.2007.06.001.
6. Hillier A. Childhood Overweight and the Built Environment: Making Technology Part of the
Solution Rather Than Part of the Problem. Ann Am Acad Polit Soc Sci. 2008;615(1):56-82.
doi:10.1177/0002716207308399.
7. Acevedo-Garcia D, Lochner KA, Osypuk TL, Subramanian SV. Future Directions in Residential
Segregation and Health Research: A Multilevel Approach. Am J Public Health. 2003;93(2):215-
221. doi:10.2105/AJPH.93.2.215.
8. Boardman JD. Stress and Physical Health: The Role of Neighborhoods as Mediating and
Moderating Mechanisms. Soc Sci Med. 2004;58(12):2473-2483.
doi:10.1016/j.socscimed.2003.09.029.
9. Williams DR, Collins C. Racial Residential Segregation: A Fundamental Cause of Racial Disparities
in Health. Public Health Rep. 2001;116(5):404-416. doi:10.1093/phr/116.5.404.
10. Krugers HJ, Arp JM, Xiong H, et al. Early Life Adversity: Lasting Consequences for Emotional
Learning. Neurobiol Stress. 2017;6:14-21. doi:10.1016/j.ynstr.2016.11.005.
11. Ross CE, Mirowsky J. Neighborhood Socioeconomic Status and Health: Context or Composition?
City & Community. 2008;7(2):163-179. doi:10.1111/j.1540-6040.2008.00251.x.
12. Townshend T, Lake A. Obesogenic Environments: Current Evidence of the Built and Food
Environments. Perspect Pub Health. 2017;137(1):38-44. doi:10.1177/1757913916679860.
13. Gordon-Larsen P, Nelson MC, Page P, Popkin BM. Inequality in the Built Environment Underlies
Key Health Disparities in Physical Activity and Obesity. Pediatrics. 2006;117(2):417-424.
doi:10.1542/peds.2005-0058.
14. Valera B, Sohani Z, Rana A, Poirier P, Anand SS. The Ethnoepidemiology of Obesity. Can J Cardiol.
2015;31(2):131-141. doi:10.1016/j.cjca.2014.10.005.
15. Cummings KM, Fong GT, Borland R. Environmental Influences on Tobacco Use: Evidence from
Societal and Community Influences on Tobacco Use and Dependence. Annu Rev Clin Psychol.
2009;5:433-458. doi:10.1146/annurev.clinpsy.032408.153607.
16. Warren JC, Smalley KB, Barefoot KN. Perceived Ease of Access to Alcohol, Tobacco and Other
Substances in Rural and Urban Us Students. Rural Remote Health. 2015;15(4):1-10 Available
from: www.rrh.org.au/journal/article/3397. Accessed February 12, 2018.

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