Stress Pathways to Health Disparities: ACEs, Social Disadvantage, and Protective Factors

Background/Purpose: Lifecourse models of persistent inequalities in physical and mental health statuses argue for integration across disciplinary analyses that have emphasized social determinants (Adler & Stewart, 2010) and early life exposures to stress and trauma as childhood roots of later life illness (Edwards et al., 2003). Consistent with social work approaches, this paper embeds ACEs within a multivariate risk and resilience factor framework. Our analysis builds on conceptual integration, specifying underlying neurobiological and psychosocial etiological mechanisms, with implications for interrupting trajectories of stress proliferation and embodiment as well as fostering health restoration (Pearlin et al., 2003).

Methods: A population-based state survey through the Behavioral Risk Factor Surveillance System (BRFSS) constitutes the sample (stratified random sampling of household adults, CDC, 2011). The study sample (n=7,470) consisted of 59.9% females, average age of 55 (SD=16.1), with income and education levels representative of the region. Demographics: age, sex, and race/ethnicity; socioeconomic factors: education and income. Aggregated ACE scores (sums across 8 categories of adversity experienced before age 18). Protective factors included socioemotional support (how often received emotional/social support) and exercise (total minutes weekly moderate/vigorous exercise). Physical health outcomes: chronic illness index (sum of 8 chronic health conditions), unhealthy days (number of days illness impaired daily living), and subjective health (respondents’ overall wellness). Indicators of physiological dysregulation consistent with theorized embodiment of cumulative stress load as well as current barriers to health care access were also assessed.

Results: Hierarchical regressions of the three physical health indicators utlized four blocks of predictor variables: 1) demographics, 2) social disadvantage, 3) ACE score, and 4) protective factors. For each of the adult health outcomes, the full regression models achieved significance, and each of the 4 predictor blocks added significantly to the R² change. As hypothesized, both ACE and socioeconomic factors significantly explained poorer health, controlling for shared variance with all other predictors. Race was partially contributive, with African American and Hispanic respondents most adversely affected. Exercise and socioemotional support provided separate protective contributions. Finally, ACE scores were significantly associated with all physiological indicators of stress embodiment and barriers to health care access, which increase the risk of longer lasting and more serious illness.

Conclusions/Implications: This study extends prior epidemiologic examinations, providing a more contextualized, multivariate assessment of the combined and distinctive impacts of early life stress as well as social disadvantage relative to adult health. In the discussion, we elaborate the theoretical basis for integrating these relatively separated lines of health disparities research and implications of findings within a social work/justice framework. Health resilience offered by both health habits and socioemotional support net of all risk factors shapes our discussion of preventive and remedial intervention implications. That these findings controlled for age effects argues for relevance across stages of adulthood and, thus, a wide range of social work service provision.