Date of Award


Degree Type


Degree Name

Doctor of Philosophy (PhD)


Public Health

First Advisor

Shannon Self-Brown

Second Advisor

Douglas Roblin

Third Advisor

Lawrence Barker


Chronic disease is a major health burden in the United States, affecting about half of adults, and leading to poor health, disability, and death. However, the burden of chronic disease is not shared equally among Americans, with some groups (created by determinants such as race/ethnicity and socioeconomic resources) experiencing higher rates of morbidity and mortality. When measures of health and socioeconomic resources are examined together, a stepwise gradient pattern emerges. This social gradient has been established for individual measures, such as household income and social class, and several measures of morbidity and mortality. However, nationally, little research has been conducted using area-level measures, such as county economics, to examine its relationship with chronic disease.

Three studies were completed using data from the Behavioral Risk Factor Surveillance System (BRFSS). County economic status was determined using unemployment, per capita market income, and poverty. The first study examined the relationship between county economic status and chronic disease and risk factors, both nationally and by metropolitan classification, using data from BRFSS 2013. Further, the social gradient was explored. The second study also used data from BRFSS 2013 to examine county economic status and prevalence of hypertension, arthritis, and poor health, after controlling for known risk factors. This study also examined results by US region. Finally, the third study assessed changes in disparities between persistently poor and persistently affluent counties for heart disease, hypertension, arthritis, and diabetes using data from BRFSS 2001-2010.