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TOPIC 6. CUMULATIVE ADVERSITY AND HEALTH INEQUALITIES |
Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York.
Address correspondence to Stephani L. Hatch, Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York 10032. E-mail: slh2020{at}columbia.edu
Abstract
This article focuses on cumulative adversity and protective resources, both social and biological, that interrupt or deflect individuals from optimal life-course trajectories and contribute to widening gaps in health. Under the guiding framework of cumulative adversity and/or advantage, this narrative discusses the theoretical framework of cumulative adversity, presents identified sources of cumulative adversity and protective resources, and highlights the utilization of the life-course approach. Numerous social and biological adverse conditions are identified across multiple domains. Utilizing the life-course perspective in identifying early life determinants and the paucity of information regarding identified protective factors are discussed. Understanding health inequalities requires attention paid to heterogeneity in the impact of social statuses as well as sources of cumulative adversity and protective resources within diverging trajectories across the life course. Intervention implications are discussed, and suggestions for future research are made.
IDentifying sources of cumulative adversity and protective resources across the life course is paramount in understanding health inequalities. Cumulative adversity and protective resources have consequences for mental and physical health over the life course by placing individuals at greater risk and/or providing protective and adaptive resources. This occurs through the organization of individuals' lives, varying conditions (both adversities and advantages), and changing responses to these conditions (Pearlin & Skaff, 1996
). Inequality is constructed over time as an interaction between individual behavior and experiences within diverse life circumstances and social institutional arrangements that operate both to their benefit and disadvantage (O'Rand, 1996). Understanding health inequalities requires attention paid to persistent effects of social statuses (e.g., socioeconomic status [SES] of origin, race/ethnicity, gender, and age) and sources of cumulative adversity and protective resources leading to diverging trajectories and heterogeneity within cohorts across the life course (O'Rand & Henretta, 1999; Kerckoff, 1993).
This article focuses on cumulative adversity and protective resources, both social and biological, that interrupt or deflect individuals from optimal life-course trajectories and contribute to widening gaps in health. First, conceptual specification and the nature of cumulative adversity and advantage will be discussed. This entails a presentation of the theory of cumulative adversity/advantage and identified sources of cumulative adversity that may contribute to illness and impairment. Second, utilization of the life-course paradigm is considered. Finally, protective resources over the life course are discussed.
CUMULATIVE ADVERSITY AND ADVANTAGE: CONCEPTUAL SPECIFICATION
Merton (1968) initially introduced the concept of cumulative advantage to explain inequality in productivity and recognition among scientists. Merton argues that inequality results from the unequal distribution of resources supporting productivity, with recognition leading to further productivity, and increasingly working to the advantage of few and the disadvantage of most. The cumulative advantage hypothesis predicts heterogeneity in trajectories through exposure to adversity and advantage organized around key transitions that increase relative inequality over the life course (Crystal & Shea, 1990; Dannefer, 1988). Increasing heterogeneity in cohorts accentuates individual health differences that occur during the aging process. Heterogeneity, defined by Blau (1977) as variability on a given characteristic, is often conceptualized as inequality where it implies variation in ranked conditions and results from differential allocation and accumulation of adversities and advantages (Mirowsky, Ross, & Reynolds, 2000). The guiding principles of cumulative advantage serve to demarcate mechanisms producing diverging trajectories to help explain changing health inequalities from childhood to adulthood (Dannefer, 1987).
The cumulative advantage hypothesis has been applied in various studies of economic inequality by age (Dannefer, 1987, 1988; Kerckoff, 1993; O'Rand, 1996). Research on education attainment and health (Ross & Wu, 1996); occupational careers and labor markets (Kerckoff, 1993); income (Crystal & Shea, 1990); economic hardship and physical impairment (Mirowsky & Hu, 1996); and gender, SES, and functional impairment (Maddox & Clark, 1992) also present findings supporting the hypothesis of cumulative adversity and/or advantage.
As a concept, the strengths of cumulative adversity/advantage exist in its dynamic characteristics that develop over time, making it inherently inseparable from the life-course issue. Cumulative adversity and advantage implies that well being is not simply a consequence of an isolated circumstance but the result of circumstances that evolve over time. Several ambiguities exist in the cumulative adversity and advantage literature. The nature of cumulative adversity and/or advantage and the location of cumulative adversity and/or advantage remain unclear in the manner in which they are applied and discussed.
Cumulative adversity/advantage generally is characterized as a successive addition of circumstances leading to diverging patterns or increasing inequality over time (O'Rand, 1996). However, the nature of the cumulative process potentially occurs through three distinct but overlapping processes. First, cumulative adversity or advantage can pertain to a single hardship or protective factor in people's lives to which they become sensitive, and is characterized by its persistent and continuous effects (e.g., economic strain, health habits). Second, it can be considered as a chain of contingencies. This involves one hardship being surpassed by the next, with one condition overtaken by the next in a serial unfolding of hardships (i.e., stress proliferation). Finally, it can occur in a layering effect with one hardship remaining present and the next building on top of it in a cascading sequence. This underlying process of accumulation involves the amassing of multiple smaller effects into larger consequences (Mirowsky & Ross, 2003).
Conceptual specification of cumulative adversity and advantage and determining what aspects of it affect health and well being require acknowledgment that all sources relate back to social status positions (e.g., SES, race/ethnicity, gender, age), and all evolve over some portion of the life course. Critical social status positions function through factors that regulate status attainment by shaping opportunities and experiences, differential access to resources, and exposure to cumulative adversity and advantage across multiple domains over the life course (Pearlin, 1989).
Cumulative Adversity and Health
A wide array of adverse circumstances and advantages, which potentially impact individuals' health and well being and are distributed unevenly throughout the population, exist. Few studies provide detailed comprehensive identification of the social and biological mechanisms of cumulative adversity and advantage (both distal and proximal) that impact mental and physical health in adulthood (Maddox & Clark, 1992; McLeod & Kessler, 1990). A myriad of context-dependent vulnerabilities and socioeconomic conditions (such as poor nutrition, substandard housing conditions, residential stability, crowding, poor neighborhood quality, and other environmental exposures), limited access to health care, chronic strains, and stressful life events potentially result in the onset and course of poor mental and physical health. Effects are cumulative across the life course and impact the distribution of fundamental resources necessary to secure opportunities and upward social mobility.
Utilizing the Life-Course Approach in Identifying Early Adversity
The life-course approach generally focuses on the impact of historical context on the interplay of individuals' lives, including how social structures reinforce or ameliorate inequalities through heterogeneity within cohorts (O'Rand, 1996). All adversity and advantage is experienced in different ways under varying circumstances, and depend on social status position. Hardships are organized around transitional experiences involving major social roles, the quality of those roles, and later separation from those roles. Taking advantage of this perspective in assessments of cumulative advantage/protective resources involves examining health inequalities revealed through structural opportunities and constraints beginning at very early life periods and operating through various transitions (Kerckoff, 1993).
By tracing cumulative adversity and advantage back to its source, it becomes evident that it begins long before the birth of a child (e.g., household of origin characteristics) and has a regulatory effect on status attainment. Adversity (e.g., poverty in family of origin, larger family system competing for household resources, and single-parent household) often exists before adult status is obtained. For example, childhood social class is predictive of poor cardiovascular disease outcomes, net of current social class (Mirowsky, Ross, & Reynolds, 2000; Mishra, Ball, Dobson, & Byles, 2004).
Beginning with early-life adversity also makes it possible to determine the independent effects of social status of origin and achieved social status positions. Social mobility creates an opportunity for improvements through connections to the fundamental aspects of social status positions that influence health. For example, upward social mobility among parents tends to increase educational attainment and the adult health of their offspring (Mirowsky & Ross, 1998; Wadsworth, 1997).
Sources of adversity become avoidable for those in certain social status positions according to the fundamental cause argument (Link & Phelan, 2000). Members of higher social class status possess the earliest opportunity to have access to more education, training, skill, opportunity, and resources (Syme, 1998). Thus, the relationship between SES, intervening adversity/protective resources, and health should be considered as dynamic, changing over time, and potentially affected by social mobility. Focusing on cumulative adversity and advantage undoubtedly will produce evidence of status attainment and what differentiates those whose trajectories are flattened versus those who are upwardly mobile.
Studies of cumulative adversity also provide the opportunity to combine the strengths of the stress process and life course research. Research combining the two perspectives allows for the study of changing lives with a focus on heterogeneity (Pearlin & Skaff, 1996). These two paradigms share a focus on historical circumstances providing context for people's experiences, the timing and sequencing of transitions into and out of social roles, personal and social resources, and an interest in outcomes resulting from long-term processes (Pearlin & Skaff, 1996).
A life-course approach provides the opportunity to explore the timing of exposure to adversities and opportunities (Kerckoff, 1993). The accumulation of fateful adverse events over the life course often begins with early exposure and is likely to have a strong impact on mental and physical health throughout adulthood (Turner, 2003). Adverse exposures extend beyond the distribution of fundamental resources (e.g., family economic strain, educational attainment, and poor housing) into other context-dependent areas such as exposure to traumatic life events and environmental threats. Research suggests that the incidence of eventful stressors may decrease as people transition from midlife to older age (Ensel, 1991; Pearlin & Skaff, 1996). It is likely that older people are exposed to different types of eventful stressors as they transition out of social roles more prominent in early adulthood. For example, events such as death or illness of spouse and chronic financial strain are more likely to increase among older people (Pearlin & Skaff, 1996).
The accumulating and compounding experiences of adversity, in combination with the timing of certain transitions into and out of institutional roles, may accelerate and heighten the deleterious effects for those individuals from disadvantaged groups (Pearlin & Skaff, 1996). For minorities or marginalized individuals, adverse experiences are fundamentally exacerbated by stigma, prejudice, and discrimination at individual and institutional levels, and have strong effects on health outcomes (Kessler, Mickelson, & Williams, 1999; Williams, 1999). Perceived discrimination can be considered an acute stressor, a repeated strain, or simply as an anticipated adverse experience. Lifetime experiences of prejudice and discrimination also stand as barriers to education and, therefore, status attainment.
Intertwined Social and Biological Trajectories Over the Life Course
The life-course perspective also allows for an interdisciplinary approach that combines the structural influences producing intertwined trajectories of social experiences and opportunities with biological conditions necessary to trace the complex history of illnesses (Wadsworth, 1997). This approach enables researchers to stringently test the association between early life exposures and later disease development with potential biological pathways consisting of mediators and confounding factors that parallel or intensify the effects of social and experiential factors.
The cumulative adversity/advantage framework highlights biological factors present in early life that potentially accumulate and anchor diverse trajectories in later life (Crystal & Shea, 1990). Beginning with prenatal exposures such as mother's nutrition, researchers have identified undesirable sources of adversity (e.g., low birth weight, low cognitive functioning, chronic childhood illnesses, smoking, excessive drinking, and high body mass index [BMI]/obesity) that accumulate and act as determinants of poor adult mental and physical health outcomes (Cohen, Farley, & Mason, 2003; Marmot et al., 1991; Mirowsky & Ross, 2003). Evidence from one of the few birth cohorts currently being followed, the 1946 Birth Cohort, suggests that low birth weight yields higher systolic blood pressure in midlife and plays an important role in the development of cardiovascular disease in adults (Wadsworth, Cripps, Midwinter, & Colley, 1985). Although this type of research identifies an association between adverse factors found at earlier and later time points, illustrating cumulative adversity here would require showing that the effects of early disadvantages remain during the progression of the life course and contribute to the production of other disadvantages and even larger effects on health.
Understanding stressors in biological pathways focuses on numerous effects of hyperactivity within various systems and physiological changes similar to social pathways generated during the development of diseases and disorders (Joynt, Whellan, & O'Connor, 2003; McEwen, 2000). The notion of allostatic load refers to a cumulative process within the organism, but how does this operate with external sources of adversity/advantage that impinge on the organism? Addressing this question requires attention to the social and biological factors that are paired in some individuals and not others (Mirowsky & Ross, 2003). Research is needed to address the accumulation and amplification processes producing cumulative adversity/advantage within both types of pathway, particularly at points where the pathways intersect and affect health.
An important component of this work lies in equal consideration of health benefits or protective factors within these pathways. The next section considers protective factors present over the life course and linked to core social statuses and social institutions.
Protective Factors in the Face of Adversity
As with sources of adversity, protective factors are unevenly distributed by social status, accumulated over the life course, and related to health (Jessor, Turbin, & Costa, 1998; Lachman & Weaver, 1998; Lin, Ye, & Ensel, 1999; Lincoln, Chatters, & Taylor, 2003; Mirowsky & Hu, 1996; Seeman & Chen, 2002; Turner & Lloyd, 1999). Protective factors are thought to increase the likelihood of positive health behaviors and potentially buffer or moderate the impact of adverse conditions (Schieman & Meersman, 2004). However, individuals exposed to the same protective circumstances do not share the same experiences or traverse the same life-course trajectories. Further, resources may reinforce current trajectories of cumulative adversity/advantage in some instances and not in others. The differential processes of protective factors deserve more attention.
Protective resources offer the opportunity to break out of current life-course trajectories. For example, perceived sense of control or mastery resulting from military experience and other structured institutions may provide individuals involved in criminal behavior an opportunity to take a different pathway at a transitional point over the life course (Laub & Sampson, 2003). Protective resources potentially have a redirecting effect on trajectories by making an impact at key points of life transition. The timing and sequencing of the amplification process underlying cumulative adversity/advantage may be crucial at major life transitions including, but not limited to, entering the workforce early, development of interpersonal relationships, the integration of peer groups, and religious involvement.
Some research evidence suggests that psychosocial factors, such as mastery and social support, are key links in the association between social statuses or membership in social institutions and health. For example, Lachman and Weaver (1998) showed the moderating effects of perceived control; those in the low-income category with high sense of control had comparable health to those in the highest income group in an analysis of data from three national probability samples of men and women between the ages of 25 and 75. In another study, Lincoln and colleagues (2003) used data from the National Comorbidity Study to show that personal control operates as a mediator in the relationship between negative familial interactions and psychological distress, independent of race, among African American and white adults between the ages of 18 and 54. In yet another study, Wickrama, Lorenz, and Conger (1997) analyzed longitudinal data on married couples to show that sense of control is also associated with health-risk behaviors, which, in turn, are related to physical health status. Mastery provides a global sense of control over forces affecting individuals' lives (Pearlin, 1999). The advantage lies in having a sense of personal control over the events that impinge on one's safety, quality of life, and health (Ross & Wu, 1995; Syme, 1998).
Social support, informal instrumental and perceived emotional, impacts the effects of adversity, poor mental health, and mortality rates (Kawachi, Colditz, Ascherio, & Rimm, 1996; Lin & Peek, 1999; Sampson & Laub, 1990). Social support operates differently depending on social and economic circumstances. How supportive networks function matters, especially when individuals have little to no access to persons living outside their disadvantaged circumstances. Social support also is linked to the utility of size, density, and quality of social networks, participation in community activities, and community structure (Lin et al., 1999). Research evidence supporting the protective effects of social support is present throughout the life course. For example, Jessor and colleagues' (1998) social support strongly correlated to positive health practices in a sample of adolescents between the ages of 15 and 18. This finding is particularly important given the previously mentioned relationship between health practices and health status. In an analysis of an adult sample, Lin and colleagues (1999) showed direct protective effects of structural supports (e.g., belonging–bonding–binding through social networks and integration) and functional supports (instrumental–expressive) against depression.
Related to mastery and social support are other related types of social protective factors such as mattering, modeled positive health behaviors, involvement in prosocial activities, and church attendance (Jessor et al., 1998; Krause, Ingersoll-Dayton, & Liang, 1999; Taylor & Turner, 2001). Social institutions, such as religion, operate through many potentially protective channels, including increased belongingness and bonding provided by social integration and social support. This may be particularly important for those from marginalized or disadvantaged groups. For example, Chatters, Taylor, Lincoln, and Schroepfer (2002) argued that religion provides access to valued group practices, access to people from more advantaged social classes, and increased social support.
Through a research literature too vast to be covered in greater detail here, we know a considerable amount about the powerful effects of social support, mastery, and social attachments. However, given the potential for protective factors to temper the impact of adverse circumstances, little is known about additional protective resources from multiple life domains. How processes of accumulation and amplification operate over the life course, which factors limit their efficacy, and what causes them to diminish over time remain understudied. Individuals potentially benefit from cumulative advantage when the lasting effects of multiple protective resources leave an individual less dependent on any single protective factor. Better understanding of the cumulative advantage process may lead to greater comprehension of individuals' ability to access and substitute protective resources when confronting stressors and strains or avoiding deleterious health outcomes (Mirowsky & Ross, 2003).
DISCUSSION AND INTERVENTION IMPLICATIONS
Identifying diverging trajectories of cumulative adversity and protective resources provides the potential for greater understanding of how structural influences and social and biological factors lead to health inequalities over the life course (O'Rand & Hamil-Luker, 2004). The life-course perspective offers a framework for exploring cumulative adversity and protective factors through multiple, dynamic interdependent trajectories regulating status attainment, social mobility, as well as access to health information and care (Elder, 1994).
Based on even the most cursory interpretation of the findings on social status, cumulative adversity/advantage, and health, the implications of the evidence and resulting interventions center around two main concerns: a window of time early in life and the far-reaching arm of education. Intervening earlier in the life course creates the opportunity to impart protective resources with the hope of improving resolve, strengthening a sense of mastery, and lessening the impact of adverse conditions and hardships. Interventions must target individuals carrying the burden of established physiological, social, and economic hardships present in childhood and unrelenting in adulthood.
Another target for intervention considers the one identified factor that begets poverty, unemployment, positioning in unsatisfactory work conditions, low mastery or control, and economic hardship/strain—education and the conditions regulating its attainment. The effects of education are complex, dependent on quality, and evident throughout the life course, and they contribute to cumulative adversity and poor health (Mirowsky & Ross, 2003). Limited education has the capacity to accelerate stress proliferation, especially among those in low-income groups experiencing socioeconomic and physical hardships. As Mirowsky and Hu (1996) point out, education stabilizes by early adulthood. This makes it both easy to capture and assess within heterogeneous life trajectories and tempting to oversimplify. Researchers studying education should begin to focus on factors beyond years of schooling and incorporate access and quality of education into their measures. Exposure to lower quality educational resources potentially produces marginal employment careers in much the same way higher quality education generally leads to more employment in formal sectors, higher occupational status, and greater accumulation of wealth.
Status-influenced adversities such as low educational attainment, work outside of the mainstream and formal economy, and low-income attainment are paramount in understanding the nature of diverse trajectories over the life course. A focus on heterogeneity in employment trajectories requires the inclusion of more marginalized individual experiences (e.g., movement in and out of the paid formal economy) in our analyses (Ross & Wu, 1995). Individuals working within the informal economy, the unemployed, and those individuals who engage in unpaid domestic labor at various points over the life course are excluded from studies measuring SES by employment and occupational status (O'Rand, 1996; Ross & Wu, 1995). A more inclusive strategy in research generates findings relating adverse working conditions and economic marginality to elevated health risks among men of low SES from all racial/ethnic groups (Williams, 2003).
Understanding inequalities in health requires greater understanding of heterogeneous experiences of cumulative adversity and/or advantage, both related to social statuses and a result of achievement in and attachment to social institutions (e.g., education, family, religion, and formal/informal economy), over the life course. Research efforts focusing on cumulative adversity/advantage, within both biological and social pathways, inevitably will be a tremendous mark of progress toward this end.
Acknowledgments
I thank Leonard Pearlin for his insightful comments on all drafts.
References
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  S. L. Hatch, L. Feinstein, B. G. Link, M. E. J. Wadsworth, and M. Richards The Continuing Benefits of Education: Adult Education and Midlife Cognitive Ability in the British 1946 Birth Cohort J. Gerontol. B. Psychol. Sci. Soc. Sci., November 1, 2007; 62(6): S404 - S414. [Abstract] [Full Text] [PDF]
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 K. F. Ferraro Imagining the disciplinary advancement of gerontology: whither the tipping point? Gerontologist, October 1, 2006; 46(5): 571 - 573. [Full Text] [PDF]
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