Place-based stress and chronic disease: A systems view of environmental determinants

Abstract

The global burden of chronic diseases (CD) has resulted in significant negative societal impacts, such as long-term disability, premature death and costs to health care systems (Cohen et al. 2007; Daar et al. 2007); a recent estimate suggests that such diseases account for approximately 60% of all deaths worldwide (Daar et al. 2007). As social epidemiologists begin to more closely investigate how environmental circumstances contribute to social disparities in CD, such as cardiovascular -disease, diabetes, obesity and asthma, there has been growing interest in the mediating role of chronic stress. To date, many studies have speculated about the relevance of this pathway. However, stress-related mediation is rarely examined directly in epidemiologic research; and when it has been, it has often not been rigorously -conceptualized and a biomedical focus has been predominant. As a result, the potential mediating role of stress in CD disparities has been vaguely described and, -arguably, over-simplified in epidemiology. In this chapter, a multidisciplinary narrative review of the stress discourse is presented to facilitate a deeper understanding of inter-relationships among these factors, including how social and physical attributes of the environment can shape the experience of stress and how physiological and behavioural responses that characterize chronic stress can directly and indirectly foster chronic disease via multiple, overlapping pathways over time. In particular, the experience of stress is described in terms of sources, mediators and manifestations based on work from the disciplines of sociology, psychology and psychoneuroimmunology, and then integrated with notions of place from geography in order to facilitate a complex understanding of sociospatial disparities in CD. A conceptual framework is also presented that articulates a systems view of two key general pathways describing environmental determinants of chronic stress and CD. This tool can be used to support the development of elaborate hypotheses and study designs on this topic in social epidemiology and to support translational work related to chronic disease prevention.