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Author ORCID Identifier



Open Access Dissertation

Document Type


Degree Name

Doctor of Philosophy (PhD)

Degree Program

Public Health

Year Degree Awarded


Month Degree Awarded


First Advisor

Elizabeth Bertone-Johnson

Second Advisor

Brian Whitcomb

Third Advisor

Ken Kleinman

Fourth Advisor

Stuart Chipkin

Fifth Advisor

Karen Ertel

Subject Categories



Cardiovascular disease (CVD) is the leading cause of death in the United States. Diabetes mellitus, hypertension, and dyslipidemia are three primary risk factors for CVD. Each is disproportionately distributed in the population by race/ethnicity. Social determinants of health (SDoH) research indicate that social and environmental factors upstream of individual behaviors can impede an individual’s chronic disease control. Guided by Michael Marmot’s SDoH theoretical framework and by an ecosocial approach, this study used data from a cross-sectional mixed methods study conducted in Western Massachusetts at a federally qualified health center from 2014 to 2018 (RxHL) to examine the association between SDoH—food insecurity and social stressors—and cardiometabolic disease control. Based on the theoretical framework, self-reported and pill count medication adherence were assessed as a possible mediator of the exposure/outcome relationship.

In Chapter 1, we situated social determinants of health and cardiometabolic disease control within a social epidemiologic approach using Michael Marmot’s social determinants of health and an ecosocial theoretical framework to address the concept of embodiment.

In Chapter 2, we examined food insecurity, medication adherence, and cardiometabolic disease control and examined mediation by self-reported medication adherence. We had unexpected null findings for food insecurity and diabetes control and hypertension control. Food insecurity was independently associated with higher lipid levels. Self-reported medication adherence partially mediated the association between food insecurity and dyslipidemia as measured by Non-HDL-C.

In Chapter 3, we examined social stressors, medication adherence, and cardiometabolic chronic disease control.Unexpectedly, there was no association observed between social stressors and glycemic control among those with diabetes or SBP control among those with hypertension. Adjusted multivariable analyses indicated social stressors were independently associated with higher lipid levels as measured by LDL-C. Self-reported medication adherence partially mediated the association between social stressors and LDL-C.

In Chapter 4, we examined racial/ethnic differences in social determinants, medication adherence and cardiometabolic disease control. Using linear and proportional odds models, predicted continuous outcomes and predicted prevalence, and pairwise comparisons, we found race/ethnicity was independently associated with each outcome variable compared to non-Hispanic whites controlling for covariates. Pairwise comparisons highlighted additional significant differences between groups.


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Epidemiology Commons