Date of Graduation

2015

Document Type

Dissertation

Degree Type

PhD

College

School of Public Health

Department

Epidemiology

Committee Chair

Stephanie J Frisbee

Committee Co-Chair

Thomas K Bias

Committee Member

Peter R Giacobbi

Committee Member

Matthew J Gurka

Committee Member

Thomas Hulsey

Committee Member

Donald M Lloyd-Jones

Committee Member

Motao Zhu

Abstract

Introduction: Despite advances in treatment and decreases in risk factors, more than 80 million Americans are living with cardiovascular disease and it remains the cause of 1 in 3 deaths in the United States. A thorough understanding of health determinants requires inclusion of factors at multiple levels of proximity to individuals. The overall objective of this project is to determine the associations between cardiovascular health and socioeconomic and demographic factors, health resource availability, and state health resource policies. The central hypothesis of this project is that higher cardiovascular health is associated with having evidence-based policies that promote the availability of health care resources, particularly those that support preventive and primary care.;Methods: 2011 Behavioral Risk Factor Surveillance System survey data were used to calculate American Heart Association's cardiovascular health index (CVHI) for individuals. County variables were abstracted from Area Health Resource File. Poisson regression was used to determine the association between individual/county/state characteristics and CVHI.;Results: County population attainment of Healthy People 2010 objectives of cardiovascular health components was very low. CVHI was poorest in the Southeast and Appalachian regions. CVHI decreased from 3.73 +/- 0.01 in 2003 to 3.45 +/- 0.01 in 2011. The majority of states experienced decreases in mean CVHI and an increase in the prevalence of poor CVHI in their population between 2003 and 2009. Educational attainment, whether at the individual level or county level, had a comparatively large influence on CVHI when compared with other factors. While individual factors had the greatest impact on individual CVHI, community characteristics were able to modify the relationship between individual characteristics and CVHI. The poorest individuals benefited from living in higher income areas while higher income individuals benefited when in lower income areas. Higher density of an individual's race/ethnicity in their community was associated with higher CVHI. Primary care physician and physician assistant supply were positively associated with CVHI in both community and individual-level analysis. Those individuals deriving the largest marginal benefit from increased primary care provider supply were middle aged, non-Hispanic other race/ethnicity, female, lived in a non-urban community, had a household income less than {dollar}25,000 per year, and lived in a community with low insurance coverage. Policies with the potential to increase the autonomy of primary care physicians and nurse practitioners or decrease barriers in their ability to practice were associated with higher CVHI even after controlling for provider supply.;Conclusions: This project adds to the understanding of the determinants of individual cardiovascular health by examining factors at the organizational, community, and policy levels. Interactions suggest feedback loops that create differential advantage to certain populations and may potentially increase disparities over time. These contributions are significant because they allow policymakers and public health officials to make more informed decisions about the environments and types of policies that when in place may improve cardiovascular health.

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