摘要：Objectives. To better understand the trajectory that propels people from poverty to poor health, we investigated health resilience longitudinally among African American families with incomes below 250% of the federal poverty level. Methods. Health resilience is the capacity to maintain good health in the face of significant adversity. With higher levels of tooth retention as a marker of health resilience, we used a social–epidemiological framework to define capacity for health resilience through a chain of determinants starting in the built environment (housing quality) and community context (social support) to familial influences (religiosity) and individual mental health and health behavior. Results. Odds of retaining 20 or more teeth were 3 times as likely among adults with resilience versus more-vulnerable adults (odds ratio=3.1; 95% confidence interval [CI]=1.3, 7.4). Children of caregivers with resilience had a lower incident rate of noncavitated tooth decay at 18- to 24-month follow-up (incidence risk ratio=0.8; 95% CI=0.7, 0.9) compared with other children. Conclusions. Health resilience to poverty was supported by protective factors in the built and social environments. When poverty itself cannot be eliminated, improving the quality of the built and social environments will foster resilience to its harmful health effects. Poverty is arguably the most ubiquitous, intractable, and noxious risk factor for population health. Its effects straddle acute and chronic conditions, accumulate over the life course, and are transmitted across generations. Social causation theory posits that poverty limits education and employment opportunities leaving individuals susceptible to weaker social integration, low control, depressive symptoms, and a fatalistic outlook. 1 , 2 There may be spillover effects on self-regulation through poor dietary choice, tobacco use, inconsistent personal hygiene, and episodic use of health care. These risks may act on disease onset in independent, additive ways over the life course or they may be multiplicative and interactive. 3 For African Americans, risks may be compounded through institutional discrimination and the stigma of inferiority, 4 although supportive social networks and church attendance can buffer the impact of psychological distress and bolster mental health. 5 There are urgent public health imperatives to interrupt the trajectory that propels people from poverty to poor health and to disrupt its intergenerational cycle. Reducing behavioral risk factors in individuals and improving access to health care go part of the way. More critical is an approach that addresses the built and social environments. The former encompasses buildings, roads, parks, spaces, and all other structures built or modified by urban planners. These factors influence the quality of living conditions for residents and the community context in which people interact, because it is these material and social living conditions that give rise to risk behaviors in individuals. Not all people equally exposed to adversity suffer equally. Those exposed to adversity who adapt positively are said to demonstrate resilience. 6 , 7 In the case of health resilience, positive adaptation is expressed as better health outcomes. Resilience is not a generalized individual trait. People may show resilience to some types of adversity but not to others; they may show resilience on some achievement domains but not on others; and they may fail to show resilience when adversity becomes overwhelming. 8 Hence, to distinguish people with capacity for resilience, it is preferable to apply a generic common risk schema to populations at risk, rather than identify salient characteristics among individuals with good health. Tooth loss is uniquely suited as an indicator of health resilience. It is ubiquitous, easy to measure (even by self-report), 9 and sensitive to common risk factors for health. The number of teeth that people retain and lose is indicative of their history of dental disease and its treatment by dental services throughout the life of the permanent teeth. Tooth loss is also influenced by a diverse set of sociobehavioral circumstances 10 including negative life events, low prestige, depression, needing help from others, 11 psychological stress, 12 and personality attributes such as anxiety trait. 13 Among behavioral factors, smoking is a recognized predictor for tooth loss 14 , 15 and consumption of carbonated soft drinks, 16 poor oral hygiene, 17 and episodic use of dental care are associated with higher rates of tooth loss. Our first aim in this study was to examine whether a generic common risk and protective factor schema for capacity for resilience would predict tooth retention among adults living in poverty. Our second aim was to explore whether the children of adults with the capacity for resilience had lower incidence of noncavitated carious lesions than children of more-vulnerable adults.
