How Place and Health Interact

Places where people reside hold the key to the state of health and disease manifest within and on bodies. However, connecting downstream health problems (e.g., chronic diseases) to upstream issues and characteristics of communities is challenging for most medical models and tools (1, 2).

The presence of “ downstream” health problems ( i.e., obesity, diabetes, heart disease) for large groups of people suggest that causation and solutions to health problems go beyond individual bodies defined as patients to incorporate a set of systemic institutional, social, and structural issues for bodies now defined as social beings (1, 3). Two principles of importance in place-health research are the social construction of places and embodiment.

Human geography contributes the social construction of place. Bodies that have been imprinted with external physical and social worlds are also firstly groups engaged in the social construction of places where they embellish a space with remembrances, imaginings, social relations, and the public assimilation of shared narratives (4-6).

The theory of embodiment explains how the external physical and social worlds are taken in and expressed in human biology (7-13).

Figure 1 demonstrates how both the social construction of places by groups and embodiment work together to configure and distribute opportunities in relation to socioeconomic status, race, and ethnicity (13-23).

According to the place-health model in Figure 1, differences in health, social, and economic status at the bottom of the model originate at the top with the cultural toolkit that is attached to a place or region(24). The toolkit is where the construction of place begins as social processes assign meaning to phenomena using a shared set of norms, system of beliefs, narratives, and distinctive spiritual, material, intellectual, and emotional features (25-28). It is through the public assimilation of shared narratives in any given society that groups begin to convert spaces into places (29-31).

In Figure 1 once the cultural toolkit ascribes meaning and a shared narrative, groups use those ideas to assign worth to the social status of others and sanction the distribution of societal opportunities and resources also referred to as the social determinants of health (SDOH). Further, below the cultural toolkit, other influential arenas result from the assigned meanings including (a) the institutions, policies, and systems that govern a place, and (3) the policies, rules and regulations of that place. These mutually reinforcing arenas are the SDOH in a given region that serve to regulate the place in which the citizens live(32, 33).

Finally, the bottom of the model demonstrates the concept of embodiment when it portrays how the SDOH, (i.e., experiences, opportunities, and resources) of a place get under the skin of marginalized groups by three routes: (1) influencing behavior and making behavior harmful; (2) restricting the distribution of and access to key resources; and/or ( 3) by causing deep seated, chronic anxiety and physiological stress (18, 24, 34-37).

A final principle of the place-health model are the Upstream and Downstream designations to the left of the diagram noting that a society can intentionally use its collective autonomy to work in any or all of these areas: 1) downstream, where illness already exist; 2) upstream on the structural issues including policies, systems, or regulations); or 3) furthest upstream on the cultural toolkit to explore and change the socially constructed, values, beliefs, and narratives that drive the assignment of meaning to group differences and other phenomena (2).

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