Graduation Year


Document Type




Degree Granting Department

Public Health

Major Professor

Melinda S. Forthofer, Ph.D.


Social determinants of health, Income inequality, Poverty, Social capital, Health behavior, Cardiovascular disease, Self-reported health, Mental health, Multilevel models


At present there is a reliance on behavioral interventions that have been limited in their effectiveness to reduce the public health burden of chronic disease, partly because the effects of social context on the initiation and maintenance of health behaviors is not incorporated into public health policy and practice. Yet current research indicates that there are macro-level structural and contextual influences on population health that cannot be reduced to individual or compositional effects. This study investigated the associations between social structural factors, community social context, individual characteristics, and self-reported correlates of disease. Distal influences included social structural inequalities such as income inequality and absolute deprivation or poverty. Pertinent mechanisms through which these influences might have operated on disease included social contextual factors, such as social capital.

Both political economy and the ecosocial perspective were selected to inform this study and to provide the theoretical framework from which hypotheses were derived.The design was a multilevel, retrospective, nonexperimental study using secondary data. The study linked three data sources (2001 Behavioral Risk Factor Surveillance System, Social Capital Community Benchmark Study, and U.S. Census) by Federal Information Processing Standards codes in order for individuals to be placed in their community or state contexts. Results provided mixed evidence of the direct role of structural and contextual inequalities on self-rated health. Any direct effects of social structural inequalities on the health outcomes disappeared once individual factors were included in the models. Findings demonstrated that one dimension of social capital, organizational activism, retained its significant direct effect on general health status, once individual characteristics were considered.

Conclusions suggested indirect associations whereby the negative influence of social structural inequalities on health was mediated by the erosion of social trust, which in turn was associated with engaging in risk behavior, thus increasing the odds of reporting hypertension, fair/poor general health, and mental distress. Although results were inconsistent, this study contributed to advancing Healthy People 2010 goals of increasing quality of life and reducing health disparities by advancing understanding of the multilevel nature of perceived health and the chronic diseases they predict.