Integrating the social environment with an equity perspective into the exposome paradigm: A new conceptual framework of the Social Exposome

Environmental Research 233 (2023) 116485 Available online 22 June 2023 0013-9351/© 2023 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC license (http://creativecommons.org/licenses/bync/4.0/). Integrating the social environment with an equity perspective into the exposome paradigm: A new conceptual framework of the Social Exposome Helene Gudi-Mindermann * , Maddie White, Jana Roczen, Natalie Riedel, Stefanie Dreger, Gabriele Bolte University of Bremen, Institute of Public Health and Nursing Research, Department of Social Epidemiology, Germany ARTICLE INFO Keywords: Exposome Inequalities Health equity Environmental health Social determinants of health Environmental justice ABSTRACT The importance of the social environment and social inequalities in disease etiology is well-known due to the profound research and conceptual framework on social determinants of health. For a long period, in exposome research with its classical orientation towards detrimental health effects of biological, chemical, and physical exposures, this knowledge remained underrepresented. But currently it gains great awareness and calls for innovations in rethinking the role of social environmental health determinants. To fill this gap that exists in terms of the social domain within exposome research, we propose a novel conceptual framework of the Social Exposome, to integrate the social environment in conjunction with the physical environment into the exposome concept. The iterative development process of the Social Exposome was based on a systematic compilation of social exposures in order to achieve a holistic portrayal of the human social environment – including social, psychosocial, socioeconomic, sociodemographic, local, regional, and cultural aspects, at individual and contextual levels. In order to move the Social Exposome beyond a mere compilation of exposures, three core principles are emphasized that underly the interplay of the multitude of exposures: Multidimensionality, Reciprocity, and Timing and continuity. The key focus of the conceptual framework of the Social Exposome is on understanding the underlying mechanisms that translate social exposures into health outcomes. In particular, insights from research on health equity and environmental justice have been incorporated to uncover how social inequalities in health emerge, are maintained, and systematically drive health outcomes. Three transmission pathways are presented: Embodiment, Resilience and Susceptibility or Vulnerability, and Empowerment. The Social Exposome conceptual framework may serve as a strategic map for, both, research and intervention planning, aiming to further explore the impact of the complex social environment and to alter transmission pathways to minimize health risks and health inequalities and to foster equity in health. 1. Introduction A considerable proportion of the global burden of disease is attributable to environmental factors (WHO, 2016) and complex interactions between genes and the environment (Rappaport, 2011; Sankar, 2004). But what is referred to when we talk about environment? Rappaport and Smith (2010) define environment, and particularly the detrimental effects of environmental exposures, beyond pollution, climate, and noise, stating that “(…) exposures are not restricted to chemicals (toxicants) entering the body from air, water, or food, for example, but also include chemicals produced by inflammation, oxidative stress, lipid peroxidation, infections, gut flora, and other natural processes” (Rappaport and Smith, 2010, p. 460). Krieger’s eco-social theory (2011) extends this understanding of the scope of health-relevant environmental exposures emphasizing the relevance of the social domain: The eco-social theory postulates that humans, as social beings who live in socially organized environments, embody the ecological, material, and social worlds in which they live, including the distributions of power and wealth over time and across space (Krieger, 2011). The underlying concept of embodiment (Krieger, 2005) stresses that being engaged with the surrounding world initiates transformation of bodily characteristics through the physical incorporation of that environment with consequences for gene regulation and expression. Simultaneously, this transformation feeds back, changing this very environment. Krieger, thus, emphasizes embodiment as an active and reciprocal process that is “more than just about how social conditions ‘get under the skin’“but * Corresponding author. Grazer Str. 4, 28359, Bremen, Germany E-mail addresses: [email protected], [email protected] (H. Gudi-Mindermann). Contents lists available at ScienceDirect Environmental Research journal homepage: www.elsevier.com/locate/envres https://doi.org/10.1016/j.envres.2023.116485 Received 16 December 2022; Received in revised form 21 April 2023; Accepted 20 June 2023 Environmental Research 233 (2023) 116485 2 rather represents “our bodily engagement (soma and psyche combined), individually and collectively, with the biophysical world and each other.” (Krieger, 2011, p. 222). Examples for embodied social environment come from research on biomarkers of chronic stress and accelerated physiologic aging such as telomere length and DNA methylation (Kawachi and Subramanian, 2018; Vineis and Kelly-Irving, 2019). For instance, in African American women, telomere attrition has recently been found to be influenced by interactions between institutional racial discrimination, educational attainment, and employment status (Thomas et al., 2021). Other examples for embodied social environment originate from research on neuroendocrine pathways in the context of the allostatic load hypothesis, linking adverse living conditions with health disparities (Johnson et al., 2017; Morello-Frosch and Shenassa, 2006; Ribeiro et al., 2018; Shankardass, 2012; Szanton et al., 2005). According to this evidence, environmental influences on health comprise biological, physical, chemical, and, particularly social exposures. Interest in exploring the pathogenic effects of environmental exposures has a long history. In the 1970s, formal quantitative risk assessments of chemicals focused on single exposures using simplistic ‘one exposure – one outcome’ models (Sexton, 2012). Moreover, approaches of risk factor epidemiology dominated quantitative research on environmental health. Beginning in the 1980s, the need has been emphasized to develop methods to assess total exposure, taking all exposure pathways into account (Lioy, 1990; Wallace et al., 1987) and to consider cumulative and interactive health effects of simultaneous exposures from a wide range of environmental stressors (Sexton and Linder, 2011). Against the background that psychosocial stressors linked to social inequities may increase vulnerability to detrimental health effects of environmental exposures, the approach of cumulative risk assessment as a way to evaluate combined effects of multiple physical, chemical, and social stressors on health has been proposed (Payne-Sturges et al., 2018). This need to consider cumulative effects of multiple exposures has been recently culminated in the concept of the exposome, conceptualized by Wild (2005, 2012) as the non-genetic counterpart to the genome. In his work, Wild (2012) emphasized the need to incorporate the life-time complement of the totality of all conceivable non-genetic drivers of health and disease including exposures from internal and external sources of physical, chemical, biological, and social influences. Despite Wild’s holistic approach, recent guiding work in the field of exposome research continues to focus mainly on the effect of biological, physical, and chemical exposures on health and risks to overlook the relevance of the social environment in understanding disease etiology (Neufcourt et al., 2022). On the contrary, the political movement and scientific research on social health determinants and environmental justice has emphasized for a long time the interaction of environmental and social factors in producing health inequities: Environmental hazards and benefits tend to be unequally distributed, the former congregating in populations with unfavorable socioeconomic and demographic factors (Dreger et al., 2019; Evans and Kantrowitz, 2002; Fairburn et al., 2019; Schüle et al., 2019). While health inequalities address general differences in health without normative judgement, unequal distributions which are assumed to be unfair, unjust, and avoidable, particularly when linked to social determinants of health, are referred to as health inequities (CSDH, 2008; Kruize et al., 2014; Solar and Irwin, 2010; WHO Regional Office for Europe, 2012; WHO Regional Office for Europe, 2019a; WHO Regional Office for Europe, 2019b). The need to address the inequitable distribution of exposures to negative (environmental hazards, e.g. pollution) and positive (environmental benefits, e.g. green space) environmental health influences across population groups has been stressed in terms of distributional justice in addition to procedural justice as equal treatment and involvement of all population groups in environmental decision-making (Bolte et al., 2011; Brulle and Pellow, 2006; Gee and Payne-Sturges, 2004; Zhuang et al., 2022). Moreover, besides these exposure differentials, social differences in vulnerability to the health effects of environmental exposures (e.g. effect modification) have been considered as important mechanism in environmental justice research (Bolte et al., 2011; Gee and Payne-Sturges, 2004). Despite these converging insights that recognize the entangled dependencies between social influences and health, social influences are rarely being conceptualized in a theoretically grounded way and hardly integrated into exposome research alongside other types (e.g. physical) of exposures (Neufcourt et al., 2022; Vineis and Barouki, 2022). For instance, when searching for ‘exposome’ in the title/abstract of scientific articles up until the end of 2021, 895 publications are indexed in PubMed. This number shrinks to only five publications (Arias et al., 2022; Buekers et al., 2018; Jackson and Arah, 2020; Nwanaji-Enwerem et al., 2021; Senier et al., 2017) when the keyword ‘exposome’ is combined with the search terms ‘social*’ or ‘socio*‘. Furthermore, only two of these five publications, namely the work by Nwanaji-Enwerem et al. (2021) and Senier et al. (2017), elaborated on exposome-related concepts at all, with the idea to broaden the understanding of the exposome. Nwanaji-Enwerem et al. (2021) advertise a compound exposome approach, stressing the so-called social exposome as essential for a holistic view on exposure-disease pathways. In this article, the authors do list several social indicators that have been linked to health inequities (referring in particular to structural racism), however they do not elaborate on a conceptual framework of a social exposome. Thus, of these publications, only Senier et al. (2017) propose a conceptualization of social exposures in the exposome, called the socio-exposome. The authors emphasize their socio-exposome as a multidisciplinary conceptual framework that considers environmental exposures from individual, local, and global levels and aims to integrate sociological, public health, and environmental justice scholarship (Senier et al., 2017). The authors argue against a strongly individualized path towards a personalized medicine approach as it is typically followed in genome research, but advertise a more holistic way in order to achieve broader public health goals. One of the core principles of their framework is to link biological disease pathways and social environmental forces in order to uncover how regulatory principles (of e.g. authorities, institutions) underlie structural inequalities and environmental risk inequalities (Senier et al., 2017). By a more extended search, we identified two further publications that stress the social and psychosocial domain within the exposome concept. The public health exposome from Juarez et al. (2014) highlights population-level risks across the social and policy environment, particularly stressing the socioeconomic factors with regard to exposure distributions and individual susceptibility. The authors detail their framework’s aims to integrate complex relationships between exogenous and endogenous exposures, particularly emphasizing their lifelong occurrence. The concept of the psychoexposome from Colomina et al. (2018) considers psychosocial environmental exposures in the context of psychopathology, particularly addressing the imprinting effect of early life experiences on neural circuits that may adversely alter increasing susceptibility towards psychological disorders. These few pioneer approaches within the field of exposome research are in line with the very recent claims from exposome researchers to no longer reduce social determinants of health to confounding variables but to treat social influences as overarching determinants as they have manifold downstream effects on other exposures (Neufcourt et al., 2022; Vineis, 2022; Vineis and Barouki, 2022), as is well-known according to the profound research and conceptual framework on social determinants of health (CSDH, 2008; Friel and Marmot, 2011; WHO Regional Office for Europe, 2019a). Building on this work, we aim to fill the gap that exists in the social domain of exposome research. To achieve this, we extend previous approaches by directing the focus of attention on two less explored aspects: a) systematic and comprehensive characterization of the ‘totality’ of social exposures and b) transmission pathways between exposures and outcomes, particularly incorporating insights from health inequality, justice, and equity research. Combining these focus points, we propose a novel holistic conceptual framework of the Social Exposome, with a twofold goal. The first goal is to bring together the breadth of social and H. Gudi-Mindermann et al. Environmental Research 233 (2023) 116485 3 psychosocial exposures included in the aforementioned concepts and lines of research in one all-encompassing conceptual framework. The second goal, in order to move beyond a mere compilation of social exposures, is to uncover potential transmission pathways that will advance our understanding of how (the entirety of) individual and contextual, structural social exposures translate into health outcomes. To achieve these goals, the proposed novel conceptual framework of the Social Exposome was developed in an iterative literature-based and expertise-driven research process. We, firstly, synthesized previous knowledge a) to systematize and b) to identify the social environment in order to understand structuring mechanisms that underly the interplay of the multitude of exposures. This systematic consideration of social influences is an essential pre-step, as only a holistic portrayal of the human social environment – including social, psychosocial, socioeconomic, sociodemographic, local, regional, and cultural aspects – lays the fundamental step to understand how the entirety of social exposures affects health and disease. Secondly, we extended previous concepts by identifying pathways that translate social exposures into health outcomes to further understand the link between social environment and health. Particularly, insights from research on social structures and processes behind health inequalities need to be incorporated to uncover how – especially in terms of mechanisms and pathways – social inequalities in health emerge, are maintained, and systematically drive health outcomes (Bolte et al., 2021; CSDH, 2008; Friel and Marmot, 2011; Galea et al., 2011; Gkiouleka et al., 2018; Kruize et al., 2014; Ostlin et al., 2011; Oversveen et al., 2017; Solar and Irwin, 2010; WHO Regional Office for Europe, 2012). By means of this broad method, we aimed to comprehensively capture the available research on this topic, irrespective of the underlying disciplinary field in order to complement what is, in its conception, the holistic perspective of the exposome. The results of our research, therefore, will not only be useful to the exposome research community, but can be seen as a research interface for different disciplines ranging from social to health sciences. 2. Methods An explorative approach of reviewing and synthesizing theories was applied to develop a multi-dimensional conceptual framework of the Social Exposome. This approach was inspired by a three-stage procedure by Bolte et al. (2021) and adapted to the twofold goals of the current paper. The first two stages comprised reviewing literature and establishing an overview of existing conceptual approaches to describe and understand social exposures and social inequalities relevant for health. The third stage evaluated these findings and involved data synthesis and refinement of preliminary conceptual frameworks to develop a novel Social Exposome conceptual framework. The entire development process lasted from 2020 to 2022. This conceptual paper emerged from the collaborative research project Equal-Life (van Kamp et al., 2022) and presents a newly developed conceptual framework of the Social Exposome. The exposome perspective on children’s and adolescents’ mental health and cognitive development will be specifically covered by another conceptual paper of the Equal-Life consortium (Persson Waye et al., in preparation for this special issue). Equal-Life comprises expertise from 21 European research institutions from 11 European countries and aims to gain insight on the profound impact of physical and social environment on health, looking in particular at children’s and young people’s mental health and cognitive development (van Kamp et al., 2022). 2.1. Stage One: Literature search on theory-based concepts of the social domain In the first stage, we assessed the current state of literature regarding theory-based concepts of social influences relevant for health. There were three underlying methodological considerations that structured this work. Firstly, based on our expert knowledge in the fields of social epidemiology, social determinants of health, and environmental justice, we identified a number of influential texts that have been widely acknowledged as seminal and groundbreaking in the scientific community of social and health disciplines (e.g. Bolte et al., 2010; Brulle and Pellow, 2006; CSDH, 2008; Evans and Kantrowitz, 2002; Gee and Payne-Sturges, 2004; Gkiouleka et al., 2018; Hankivsky et al., 2017; Krieger, 2011; Marmot et al., 2012; Morello-Frosch and Shenassa, 2006; Whitehead et al., 2016; WHO Regional Office for Europe, 2019a). Secondly, in the ensuing ‘snowballing process’ (Bolte et al., 2021) or ‘pearl-growing approach’ (Whitehead et al., 2016), the literature lists of these selected publications were hand searched to identify additional relevant publications. Thirdly, this identification of relevant publications iteratively continued until theoretical saturation was reached, i.e. further reading did not gain additional theoretical insights. This final selection of texts was used as a theoretical foundation in order to set the scope for a broad spectrum of health-related social exposures and to compile a set of systematization categories needed to conceptually structure social exposures. Four categories were identified: a) type of exposures, b) setting of exposures, c) timing of exposures, d) exposure patterning. These derived categories were used to systematize social exposures in the subsequent Stage Two, where we conducted a scoping review to capture the broadness of the social domain. The first two categories address the quality and extent of exposures, referring a) to what and b) in which settings individuals can be exposed. The timing category c) relates to when and how often exposures occur, particularly considering the life-course approach. The life-course perspective stresses the cumulative effect of exposures with regard to longitudinal health effects as well as sensitive or critical periods of disease development (Cable, 2014; Kuh et al., 2003; Lynch and Smith, 2005). Already when first introducing the exposome concept, Wild (2005) emphasized the need to consider the multitude of non-genetic exposures of the entire life-course from conception onwards in order to understand the progression of health and disease. Contrary to the first three individual-level categories, the category d) exposure patterning represents the population-level of social exposures, i.e. the embeddedness of individual experiences into the broader (structural) context. This contextual category refers to structural mechanisms that underly inequities in developmental and health pathways. Within this patterning contextual category, we particularly included the societal structure gender from an intersectionality perspective (Hankivsky et al., 2017; Merz et al., 2021) as an important factor contributing to health inequities (Krieger, 2003). 2.2. Stage Two: Systematic overview of social and psychosocial exposures To systematically identify concepts and frameworks that assess the social and psychosocial environment and to inform the development of our conceptual framework, a scoping review was conducted in accordance with PRISMA ScR guidelines (Tricco et al., 2018). The search syntax included a wide range of keywords and was designed for two sub-searches: a) Social environment and b) Psychosocial environment. This subdivision was introduced to ensure that psychosocial influences, as an integral feature of the social environment, will not be missed due to potential differences in the use of terminology across scientific disciplines. For the subsequent screening, records of both sub-searches were merged. The search syntax required key words to occur in the title and/or abstract. Records were limited to review articles published in peer reviewed journals or as book chapters between January 2000 and August 2020. Only research contributions limited to humans and published in English were considered. The search covered three databases that differed in their research disciplines and emphasis: PubMed (health sciences), Scopus (bio, social, natural, health sciences) and PsycInfo (psychology). The search syntax is summarized in Box 1. After merging the records of all three databases (sub-search a): 2246 H. Gudi-Mindermann et al. Environmental Research 233 (2023) 116485 4 records; sub-search b): 1489), a semi-automated de-duplication routine was applied to the 3735 results to avoid content overlap (Bramer et al., 2016). 3686 publications were identified after de-duplication. Two authors (MW, HGM) independently reviewed titles and abstracts of all publications. As we were interested in conceptually capturing the broadness of the social domain rather than addressing specific exposure-outcome associations, eligibility criteria were fulfilled only if the criterion of multidimensionality was fulfilled, i.e. the publication covered more than one category (type of exposures, setting of exposures, time point of exposures, exposure patterning) or more than one aspect (e.g. exposure, exposures patterning mechanism) within one category identified in Stage One. Applying this criterion on all 3686 Stage Two records, reviewer A identified 56 and reviewer B identified 42 relevant publications. Any disagreements about eligibility of a publication were resolved by discussion and, if necessary, by consultation of a third reviewer (GB) (total hits: 68). Subsequently, a team of eighteen experts from the Equal-Life research group rated the abstracts’ relevance of these 68 publications for full text inclusion. This team of eighteen Equal-Life researchers comprises expertise from diverse scientific and national background on environmental public health, (social) epidemiology, environmental justice, environmental and developmental psychology, and environmental medicine. The authors and experts together identified a total of 14 publications as relevant for a systematic collection and arrangement of influences of the social and psychosocial environment. The review articles were sorted in two classes based on their primary objective: “literature overview” (n =7), or a literature review with a subsequent synthesis of results into a “theoretical concept/framework” (n =7) (referred to as a conceptual paper in the following explanation). Content extraction was performed by two authors (HGM, MW). For extraction, we used the categories that were derived in Stage One (type of exposures, setting of exposures, time point of exposures, exposure patterning – social inequities, gender perspective). As we were interested in extending the exposome concept, a final additional category was included to indicate whether the identified exposure-based publication was theoretically linked to the exposome. In the extraction table, three evaluation criteria indicated whether each of the categories mentioned above was: Not mentioned in publication (−); Mentioned in publication without in-depth explanation, or without theoretical incorporation into the proposed concept for a conceptual paper (+); A detailed elaboration of category was provided, or the category was theoretically grounded in the proposed concept (++). As shown in Table 1 for all 14 reviewed publications, multidimensionality of type and setting of exposures, as required by eligibility Box 1 Search syntax of sub-searches a) and b) of the scoping review. Sub-search a): Social environment 1 “social environment*” 2 “social and built environment*” 3 “social setting*” 4 “social context*” 5 “socio-economic environment*"OR “socioeconomic environment*” 6 “socio-economic context*" OR “socioeconomic context*” 7 “socio-economic setting*" OR “socioeconomic setting*” 8 “socio-demographic environment*” OR “sociodemographic environment*” 9 “socio-demographic context*” OR “sociodemographic context*” 10 “socio-demographic setting*” OR “sociodemographic setting*“ 11 #1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 12 theor* OR mechanism* OR concept* OR pathway* OR explanat* OR framework* 13 #11 AND #12. The final search 13 comprises steps 1 to 12, that describe the successive search strategy. No differentiation of results from sub-searches (searches 1–12) will be considered. Sub-search b): Psychosocial environment 1 “psychosocial environment*” OR “psycho-social environment*” 2 “psychosocial setting*” OR “psycho-social setting*” 3 “psychosocial context*” OR “psycho-social context*” 4 “family environment*” OR “home environment*” OR “community environment*” OR “school environment*” OR “pre school environment*” OR “pre-school environment*” OR “preschool environment*” OR “day care environment*” OR “day-care environment*” OR “daycare environment*” OR “child care environment*” OR “child-care environment*” OR “childcare environment*” 5 “family setting*” OR “home setting*” OR “community setting*” OR “school setting*” OR “pre school setting*” OR “pre-school setting*” OR “preschool setting*” OR “day care setting*” OR “day-care setting*” OR “daycare setting*” OR “child care setting*” OR “child-care setting*” OR “childcare setting*” 6 “family context*” OR “home context*” OR “community context*” OR “school context*” OR “pre school context*” OR “pre-school context*” OR “preschool context*” OR “day care context*” OR “day-care context*” OR “daycare context*” OR “child care context *” OR “child-care context*” OR “childcare context*” 7 theor* OR mechanism* OR concept* OR pathway* OR explanat* OR framework* 8 #1 OR #2 OR #3 OR #4 OR #5 OR #6 9 #7 AND #8. The final search 9 comprises steps 1 to 8, that describe the successive search strategy. No differentiation of results from sub-searches (searches 1–8) will be considered. H. Gudi-Mindermann et al. Environmental Research 233 (2023) 116485 5 Table 1 Summary of exposure-based publications included in scoping review. Focus of content* Authors/Year (Alphabetical order) Scope of publication Type of exposures Setting of exposures Timing of exposures** Social inequity** Gender perspective** Link to exposome concept** CF Alwin and Wray (2005) Life-span perspective on social status and health Multidimensional perspective of social status considering: age, gender, ethnicity, education, socioeconomic differences, childhood experiences and family background Individual lifecourse, family background, societal conditions ++ Life-course ++ Institutional anchoring of social disparities ++ Embodied gender – CF Berkman et al. (2000); Berkowitz (2004) Holistic consideration of social integration/ social networks and their impact on health Social networks, social support, social ties and social integration Individual network structure within larger social and cultural context + Relevance of infancy, relevance of cohort for individual life history + Network structure shaped by social context – status, inequality – – LO Blair et al. (2014) Pathways linking neighborhood characteristics and depression Neighborhood characteristics: neighborhood deprivation; disorder, crime and perceived safety; instability, mobility; social ties, cohesion, social capital Individuals, neighborhood: physical and social environmental characteristics – – – – CF Chen and Schreier (2008) Effect of social environment on asthma Interpersonal relationships at different setting - family: quality of relationships, parental depression, stress - peers: social support - neighborhood: community socioeconomics, violence Setting of interpersonal relationships: family, peers, neighborhood – – – – CF Earls and Carlson (2001) Effect of distal social context (social ecology) on children’s health and well-being Composition, structure, function of larger social configurations: social relationships to teachers, police, neighbors, parents, peers Ecological model: family processes and individual development are embedded in community and other macrosocial structures – + Social inequalities driven by community capacity and empowerment – – LO Egan et al. (2008) Psychosocial health risks Risk factors bridging socio-structural and psychological characteristics: - autonomy and control; involvement, participation and empowerment; social capital, social cohesion, trust and belonging; - social support (including specific types of support: e.g. emotional); - social networks and receiving positive feedback - social diversity and tolerance - vulnerability, security or safety - demands, role conflicts or role imbalance Psychosocial factors as bridging or ‘mesolevel’ between individual and social structures – – – – CF Hemmingsson (2014) Causal link between Family socioeconomics Individuals embedded in family + Intergenerational + Socioeconomic – – (continued on next page) H. Gudi-Mindermann et al. Environmental Research 233 (2023) 116485 6 Table 1 (continued) Focus of content* Authors/Year (Alphabetical order) Scope of publication Type of exposures Setting of exposures Timing of exposures** Social inequity** Gender perspective** Link to exposome concept** socioeconomics and child obesity mediating protective factors: self-esteem, peer support, resilience (selfefficacy, optimism, self-esteem), functional coping skills transmission of socioeconomic disadvantage and psychological transmission of distress LO Holt-Lunstad (2018) Effect of social relationships on health and longevity Health protective factors: social relationships, social contact, family ties, social integration, social support Health risk factors: lack of social connection (loneliness, social isolation), divorce, being single, widowhood Systems approach: individual exists within a network of four separate yet embedded dimensions: individual, family and close relationships, community, society + Temporal evolution of social networks – – – LO Hong and Espelage (2012) Bullying and victimization among pupils Individual characteristics associated with bullying perpetration and victimization: age, gender, ethnicity, sexual orientation, health status (overweight), depression and anxiety, learning and developmental disabilities, poverty Bronfenbrenner’s ecological approach: individual characteristics embedded in micro-, meso-, exo-, macro-, and chronosystem – – – – CF Kruize et al. (2014) Environmental justice: relation between environmental inequalities and health effects Distributional justice: spatial distribution of environmental risks at places of work, living, playing, etc. Procedural justice: distribution process itself, including access to and participation in decision-making processes and procedures that create environmental risks Individuals, societal, communal, institutional-level refers to spatial (state) and social context (laws) ++ Life-course perspective: causal link between time and timing of exposures and outcomes within an individual life course, across generations, and in population-level diseases trends ++ Environmental and psychosocial risks accumulate in neighborhoods with lower socioeconomic status – – LO Li et al. (2008) Modernity’s paradox: Children’s health in an economically improving but unjust modern world Globally improving economy at the cost of human health: sugar industry, fast food, artificial milk, sedentary behavior, rising working hours, working times, hire arrangements Links individual (micro-level) health and societal (macrolevel) conditions. + Intragenerational transmission of socioeconomic disadvantage between life stages ++ Structural inequality – – LO Marjoribanks (2005) Relation between family learning environment and school performance Academic-relevant family characteristics: work habits, academic guidance and support, stimulation to explore and discuss ideas and events, language environment at home, parents’ academic aspirations Family environment is embedded in social context + Interand intragenerational transmission of disadvantages + Impermeability of social trajectories – – CF Pearce et al. (2019) Social determinants of child health and pathways towards health inequity Socioeconomic advantages lead to greater access to resources that support health (e.g. food, warm clothing/ footwear, housing quality, safety) Individuals, family, household, community, culture ++ Life-course perspective ++ Unequal distribution of social determinants of health lead to health inequity – – (continued on next page) H. Gudi-Mindermann et al. Environmental Research 233 (2023) 116485 7 criteria, is an essential characteristic of each of the 14 publications. The life-course perspective was incorporated in detail in only three publications (Alwin and Wray, 2005; Kruize et al., 2014; Pearce et al., 2019), and a further four embedded a social inequity perspective in their work by referring to structural disparities (Alwin and Wray, 2005; Kruize et al., 2014; Li et al., 2008; Pearce et al., 2019). Only one (Alwin and Wray, 2005) of the 14 publications elaborated on the gender perspective. None of the papers referred to the exposome conceptual framework. The review of theory-based concepts of the social domain across these 14 publications revealed that understanding the complex effects of the social environment on health and disease requires the consideration of the interplay of simultaneously acting exposures as well as considering patterning of exposures at the population-level (category d). In sum, despite a high number of published review and conceptual papers on various social exposures, patterning aspects are widely neglected in this field and the gender perspective, in particular, is underrepresented. Thus, in the following stage, we aimed at synthesizing the categories of type, setting, and timing of exposures as well as exposure patterning into a multidimensional holistic conceptual framework of the Social Exposome. 2.3. Stage Three: Iterative process of conceptual framework development and refinement In the third stage, we evaluated and integrated the results from Stage One (systematization categories for social and psychosocial exposures) and Stage Two (identification of social and psychosocial exposures). Specifically, in Stage One we reviewed theory-based concepts of healthrelevant social influences to establish a systematization concept that we used as a basis to outline the ‘entirety’ of potentially relevant social exposures to be used in an overall concept at a later stage. In Stage Two, we conducted a scoping review to identify the wide variety of social and psychosocial exposures that have been discussed in previous literature and how they have been integrated into conceptual frameworks. Based on these two steps, in Stage Three we synthesized this previous knowledge from different disciplines to organize the aggregated healthrelevant exposures into a new conceptual framework and a visual representation of a holistic Social Exposome that goes beyond the breadth of the social exposures and the associated conceptual frameworks identified in Stage Two. We derived three core principles to structure the exposures beyond a mere compilation: Multidimensionality, Reciprocity, Timing and continuity. These core principles underpin the exposures’ interrelatedness and help to extend our understanding on how the interplay of exposures, rather than a multitude of single exposures, shapes health, suggesting exposure-health transmission pathways. This framework formed the basis for the subsequent iterative process of development and refinement, involving discussions and scientific exchange, consecutively within the team of the Department of Social Epidemiology at University of Bremen (also a WHO Collaborating Center for Environmental Health Inequalities), the interdisciplinary team of the Social Exposome work package of Equal-Life, the broader Equal-Life research group, and the scientific community of the European Human Exposome Network (EHEN). The iterative process took place from 2020 to 2022. The current paper presents the conceptual framework of the Social Exposome that comprehensively portrays the multidimensional social environment and aims to systematically detect transmission pathways that translate social exposures into health outcomes in order to bridge the individualand population-levels. 3. Results: Social Exposome – A novel conceptual framework Based on the synthesis of reviewed literature, relevant social and psychosocial theories and iterative model refinement in discussion within the Equal-Life team, we propose a novel conceptual framework of the Social Exposome. This framework aims to portray the breadth of influences from the social environment. To structure the variety of social and psychosocial exposures three underlying core principles are proposed: Multidimensionality, Reciprocity, and Timing and continuity). The key focus of the conceptual framework of the Social Exposome is on understanding the underlying mechanisms that translate social exposures into health outcomes. Fig. 1 is an overall visual representation of the conceptual framework of the Social Exposome 3.1. Multidimensionality The Social Exposome conceptual framework is based on the key assumption that the entirety of a person’s social environment systematically impacts upon development and health. This social environment ranges from the immediate social environment (individual-level), up to the broadest societal context (population-level) in which the individuallevel social experiences are embedded. These multiple dimensions, visually represented as bedded circles and intersecting triangles around the centrally placed individual (Fig. 1), symbolize the constant presence of a huge variety of social exposures that, furthermore, continuously evolve over time. The core principle of multidimensionality in this conceptual framework stresses the idea that these exposures all together determine the quality of the social environment and that the social environment cannot be adequately described by considering only a single attribute from the spectrum of social exposures. For a more detailed explanation see legends to Figs. 1 and 2, Table 2 and Supplement 1. 3.1.1. Social environment dimensions The innermost circle, Social interactions, represents the most immediate dimension of the social environment within the Social Exposome. The role that social interactions play in context of the social environment cannot be overstated, as they are a prerequisite to connect the individual with the outer world and at the same time influence these connections. We use the interlinked assembly of three puzzle pieces (Table 2 Supplement 1) surrounding the individual member of a society to reflect on what we consider to be the three central elements that allow a comprehensive characterization of social interactions. Table 1 (continued) Focus of content* Authors/Year (Alphabetical order) Scope of publication Type of exposures Setting of exposures Timing of exposures** Social inequity** Gender perspective** Link to exposome concept** LO Seeman and Crimmins (2001) Relation between health and social networks, socioeconomics, community-level characteristics Social networks, socioeconomics, community-level characteristics Individuals and communities + Link between community and individual inequalities – – – *CF Theoretical concept/framework; LO Literature overview. **++In-depth elaboration in LO or theoretically grounded in CF; +Mentioned without in-depth explanation in LO or without theoretical incorporation in CF; - Not mentioned. H. Gudi-Mindermann et al. Environmental Research 233 (2023) 116485 8 a) Actors: Who is part of a person’s social network? b) Relational dynamics: What is the nature of interaction between individuals, within and across groups? c) Places: Where do social interactions take place? The Social Exposome concept emphasizes social interactions as particularly relevant within the Social Exposome, that is understood as the entirety of social exposures. It is the social interactions that make the individual experience the outer social world and can be regarded as filters that need to be crossed for connection with the social environment in which individuals are embedded. Thus, in the Social Exposome concept the impact of the broader societal context reaches individuals through social interactions. For example, Lipina (2016) emphasizes in his overview paper on the link between poverty and children’s neurocognitive development, that language exposure and stress regulation are two of the most important mediation mechanisms involved in the dynamic interplay of individual and environmental factors that influence development and health. Both of these mechanisms are pertained to social interactions, highlighting the essential impact of social interactions. The explicit characterization of social interactions is essential to understand the effect of the social environment, not only because social interactions link the individual with the outer world but also because of the significance of social relationships for health and development. The body of evidence examining the association between social interactions and health outcomes converges on the assumption that social relationships have a considerable impact on well-being (e.g. Earls and Carlson, 2001), mental health (e.g. Seeman and Crimmins, 2001), physical health (e.g. Umberson and Montez, 2010), and longevity and mortality (e.g. Holt-Lunstad, 2018; Seeman and Crimmins, 2001) to name only a few outcomes. The recent Social Baseline Theory from the field of neuroscience suggests that social (supportive relationships) and metabolic (oxygen, glucose) resources are treated almost interchangeably by the human brain, particularly in socially challenging situations (Coan and Sbarra, 2015). The authors claim that the presence of social relationships (measured in terms of interdependence, shared goals, joint attention) is expected in the brain’s default state, while their absence is perceived as lacking available resources and results in physiological and cognitive effort and negative consequences for health and well-being (Coan and Sbarra, 2015). In the Social Exposome framework, social interactions are embedded within the broader societal context, which is represented by four interrelated dimensions: Socioeconomic circumstances and Sociodemographic characteristics; Systems, institutions and priorities of the political economy; Social norms; and Cultural values. Socioeconomic circumstances and Sociodemographic characteristics are understood as dynamic influences that change in their relevance and impact across the life-course. For children, Socioeconomic circumstances are the result of the socioeconomic background of parents and caregivers: the household the child lives in, as well as the surrounding neighborhood context (e.g. area-level socioeconomic deprivation) (Graham and Power, 2004; Pearce et al., 2019). The intergenerational impact of parental socioeconomic attainment means that the socioeconomic outcomes of the child are essentially affected by the socioeconomic status of their parents (Alwin and Wray, 2005; Graham and Power, 2004; Kaplan, 2004), although these influences may rearrange and change along with the individual, e.g. in the course of education and leaving home processes. Similarly, Sociodemographic characteristics, referred to as individual attributes at a certain point in time, such as age, migration background, religious affiliation, ethnicity, and marital status, evolve during the life course and may partially change. Additionally, these attributes could be reasons for experiencing discrimination and structural injustice. Systems, institutions and priorities of the political economy determine and regulate political decisions and structures at societal level. The scope of the political economy and important aspects of it in Fig. 1. The conceptual framework of the Social Exposome. The Social Exposome concept is based on the key assumption that the entirety of social exposures systematically impacts upon development and health. The omnipresence of the social environment is symbolized by bedded circles surrounding an individual. The multiple dimensions of the social domain are hierarchically arranged in layers. The most immediate layer of the social environment comprises Social interactions, which are represented by the assembly of three interlinked puzzle pieces (Actors, Relational dynamics, Places) that together characterize the structure, function, and quality of a person’s social network. Social interactions are embedded within the broader societal context and can be regarded as filters through which the social environment reaches the individual. This broader societal context is represented by four interrelated dimensions, symbolized by grey-shaded embedded circles and a grey intersecting triangle: Socioeconomic circumstances and Sociodemographic characteristics; Systems, institutions and priorities of the political economy; Social norms; and Cultural values. All these grey-shaded dimensions, together with the puzzle pieces, represent the entirety of social exposures that shapes mental and physical development and health. The dashed lines between layers highlight reciprocity of shaping processes and interconnectedness between dimensions. The intersecting shape of a triangle, in addition to the bedded circles, symbolizes the reciprocal impact of Social norms and Cultural values on all dimensions of exposures, by also stressing that norms and values can reach right to the individual and their social interactions (symbolized by the grey ring crossing the puzzle pieces), directly imprinting their beliefs, attitudes, and behavior. The intersecting blue triangle is highlighted in color to separate it from grey-shaded dimensions of societal exposures. It represents Social inequalities and Structural injustices: Intersectionality and Gender perspective that symbolize societal forces, which form the exposures’ interplay and systematically maintain and aggravate inequity that, ultimately, feeds back through all dimensions up to the individual at the center, affecting their development and health. In the Social Exposome framework, the inner figure represents the individual as an interactive product of the surrounding social environment. Fig. 2 depicts a zoomed in version of the inner figure to ensure readability. A selection of individual characteristics that are shaped in reciprocal interaction with the social environment is listed inside the inner figure, e.g. stress sensitivity, personality, identity, skills and abilities, knowledge. Three transmission pathways, represented by rounded arrows, translate social exposures into health outcomes: Embodiment, Resilience and Susceptibility or Vulnerability, and Empowerment. The interlocked wheels symbolize external events that additionally affect the social environment. For further details, see Fig. 2, Table 2, Supplement 1. H. Gudi-Mindermann et al. Environmental Research 233 (2023) 116485 9 terms of policy, practice, processes, institutions, and legal rules is broad, as its impact on population health operates across multiple sectors and multiple levels. As outlined in a review of the impact of the political economy on population health by McCartney et al. (2019), this includes the welfare state, economic policy, public spending, the provision of education and health care services, and housing policy and provision. These policies, institutions, and priorities are largely informed by shared social norms and cultural values, as illustrated in Fig. 1 by the intersecting grey triangle, that reaches through all dimensions of exposures to the individual. In the Social Exposome conceptual framework, Social norms are regarded as being the expected and acceptable standards of behavior in particular settings and social contexts. Social norms that are prevalent in families, peer groups, and wider societal systems, including other cultural groups, can play an important role in establishing a sense (or lack thereof) of belongingness and acceptance that are central to the healthy development of a person’s own identity (Gray, 2001). Furthermore, these social norms can be understood both in terms of the perceived norms (individual’s belief about typical or standard behavior in a group) as well as the actual norms (the beliefs and actions of the group) (Berkowitz, 2004), and includes both formalized (i.e. with legalized consequences) and non-formalized norms. Cultural values in the Social Exposome represent the frame within which social norms are established, shared and maintained and includes assumptions and beliefs, as well as rules of morality. Cultural values can refer to a national Table 2 Social Exposome’s most immediate dimension of social exposures: Social interactions, consisting of the interplay of Actors, Relational dynamics, and Places. Relational dynamics Examples Place Examples Actors Examples Social climate/ atmosphere Harmony/disharmony, safety, psychological distress, parental styles Home Home environment(s), room(s), shared spaces Family Parents, siblings, other family members, and relatives Social support Emotional support, instrumental support, appraisal support, informational support, parental investment, social modelling Places for learning and working Creche, kindergarten, school, university; Office, factory, store, farm Peers Classmates/fellow students/ colleagues, friends, sports team/activity group members Social capital Access to resources driven by membership within networks, social trust, reciprocity, participation Digital world Virtual places in digital world (i.e. where games are set, chat rooms, social media) Companions Close friends, romantic/ intimate partners Medium of interaction face-to-face, telecommunications, online communication, digital identity Places for leisure time Friends’ homes, museums, movie theatres, music halls, sports fields, community centers Official figures Teachers, instructors, educators, coaches, mentors, doctors, social service agents, religious leaders Neighborhood physical environment (Physical domain) Natural environment e.g. air, climate, soil, water Acquaintances Family friends, neighbors, random contacts Built environment Buildings (e.g. housing), transportation (e.g. street connectivity), open spaces (e.g. blue spaces, green spaces i.e. parks) Digital contacts Chat groups, influencers, social media contacts Neighborhood social environment Economic domain Health-relevant economic resources e.g. supermarkets, commercial outlets Institutional domain Schools, clinics, educational institutions, professional bodies, religious facilities, municipal services (policing, sanitation) In the Social Exposome framework the metaphor of three interlinked puzzle pieces (Actors, Relational dynamics, and Places) is used to visualize social interactions, to underscore that social interactions evolve as an interplay of these pieces. Actors, in interaction with one another, create relational dynamics that define the atmosphere in which they interact and are often bound with Places, for example family with home or classmates (peers) with school. The life-course perspective, building one of the core principles of the Social Exposome concept, is implemented into the dimension of social interactions. Each puzzle piece comprises several components that change – as indicated by double-headed white arrows – in composition (number of components) and their relevance (size of components within a dimension) across the course of life correspondingly altering their impact. For example, entering kindergarten/school is naturally accompanied by the decrease in relevance of the Place home. Similarly, the differentiation within the dimension Actors evolves with age, extending to include friends, classmates, sports mates, etc., reflecting the increasing diversity in Relational dynamics. This age-dependent course of evolving social interactions exemplifies, on the one hand, a (culturally accentuated) prototypical timeline, whereas, on the other hand, it preserves individual trajectories of a life with its own history, including the individual accumulation of risk, susceptibility, etc. Further explanations and implications of the three dimensions of Social Interactions are summarized in Supplement 1. H. Gudi-Mindermann et al. Environmental Research 233 (2023) 116485 16 multidimensional Social Exposome conceptual framework, especially when data analyses are performed with already completed epidemiological studies. Nwanaji-Enwerem et al. (2021), when calling for their compound exposome approach, go in this direction, stressing area-based socioeconomic measures such as neighborhood segregation. Although the authors focus on the consideration of structural factors relating to racial health disparities, its call to action can also be understood as an argument for the consideration of structural factors in exposome research more generally because of how these interact, fostering inequity. In this way, our conceptual model – which embeds Social inequalities and Structural injustices as part of an individual’s broader context alongside other exposures from within a person’s social environment – can be seen as a conceptual building block for further work in this field. To demonstrate the practicability of the concept in exposome research and to validate the Social Exposome framework with regard to the proposed transmission mechanisms and health pathways was beyond the scope of this paper. The first practical applications of the conceptual framework or parts of it in statistical analyses using data from environmental epidemiological cohort studies and school studies of children and young people in Europe are planned in the forthcoming research of our Equal-Life project (van Kamp et al., 2022). These empirical research applications of the framework will contribute to its improvement through validation and refinement. 5. Conclusion We propose a novel conceptual framework of the Social Exposome. Up to now, a thorough theory-based conceptualization that comprehensively captures and integrates the manifold social domain within the exposome research has been lacking. The conceptual framework of the Social Exposome was developed to fill this gap. Based on the synthesis of reviewed literature and relevant social and psychosocial theories that informed our work, we incorporated the entirety of social exposures and focused on the underlying mechanisms from health equity, environmental justice, intersectionality, and sex/gender perspectives. We outlined social exposure dimensions and three core principles that underpin the proposed conceptual framework: Multidimensionality, Reciprocity, and Timing and continuity. In this framework, transmission from social exposures to health development across the life span operates via Embodiment, Resilience and Susceptibility or Vulnerability, and Empowerment. Our conceptual framework may serve as a strategic map for both research and intervention planning aiming to decode the impact of the complex social environment and to alter transmission pathways to minimize health risks and health inequalities and to foster equity in health. Credit author statement Helene Gudi-Mindermann: Conceptualization, Methodology, Writing – original draft, Visualization; Maddie White: Conceptualization, Methodology, Writing – original draft, Visualization; Jana Roczen: Conceptualization, Methodology, Visualization; Natalie Riedel: Writing – Review & Editing, Funding acquisition; Stefanie Dreger: Writing – Review & Editing, Funding acquisition; Gabriele Bolte: Conceptualization, Writing – review & editing, Visualization, Supervision, Funding acquisition Funding This work was supported by the European Union’s Horizon 2020 research and innovation program under grant agreement No 874724. Author agreement and disclosure statement All authors have seen and approved the final version of the manuscript being submitted. They warrant that the article is the authors’ original work, has not received prior publication and is not under consideration for publication elsewhere. 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