Date of Award


Degree Type


Degree Name

Doctor of Philosophy (PhD)

Graduate Group


First Advisor

Barbara Riegel


Social determinants of health (SDH) include the social, economic, and built environmental resources that define health. Inequitable distribution of these resources results in disparate health outcomes. Disadvantaged population groups experience limited access to health-promoting resources that further marginalize them from mainstream society and increase their predisposition to chronic cardiovascular diseases (CVD) such as heart failure (HF). Although prior research has linked social disadvantage to CVD risk, few studies have explored the mechanism underlying the social determinants – health outcomes relationship. The overall goal of this dissertation was to develop scholarship surrounding the relationship between SDH and HF self-care, and explore operational mechanisms underlying that relationship. Using a three-article dissertation format, chapter two of this dissertation presents a synthesis of existing literature on marginalization and situates the concept of marginalization in the SDH framework. Chapter three reports the findings of a secondary data analysis that explored the relationship between sociodemographic indicators of SDH and self-care maintenance in adults with HF. Chapter four presents the findings of a mixed methods study of SDH and HF self-care. The first aim of the study addressed the relationship between SDH and self-care in community dwelling adults with HF. The second aim explored participants’ perceptions, beliefs, and experiences surrounding SDH and self-care behavior using one-on-one in-depth interviews. In integration, differences and/or similarities in the self-reported SDH in relation to participants’ self-care behavior were described. Major findings of this dissertation were: 1) Disparities and inequity in health promoting resources increase with increased distance from mainstream society, 2) Social position serves as the link between SDH and marginalization, 3) Socio-political, economic, cultural and religious influences accentuate the marginalization of vulnerable population groups, further limiting their access to health promoting resources, 4) Race, education and marital status were associated with self-care maintenance, 5) Social connections, individual lived experiences, and type of insurance coverage are possible mechanisms underlying the SDH-Self-care relationship. This dissertation adds to current literature on the relationship between SDH and HF self-care. Knowledge gained will inform future research, clinical and policy interventions that facilitate self-care, reduce disparities, and enhance equity.


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