Sentinel Health Events, Structural Equation Model, Epidemiology, Economic Inequality, Social Disorganization


The United States currently provides a health care system that is neither efficient nor equitable. Despite outspending the world on health care, over three-fourths of developed countries produce better health outcomes (Auerbach et al., 2000). Simultaneously, the "Ecological School of Thought" has documented the large impact that social, economic, and environmental circumstances play in health outcomes. Unfortunately, these 'ecological" studies are frequently conducted without theoretical justification, and rely solely on a cross-sectional research design and a myriad of unrelated variables. This study represents an important step towards the development of a true theory of "ecology". More specifically, we argue that the adversity associated with socio-economic disadvantage, social disorganization, and a lack of health care resources, leads to adverse health outcomes, represented by sentinel health events. This research employs both a cross-sectional (2000) and longitudinal designs (1990 - 2000) to assess the antecedents of sentinel health events in 309 United States counties. Structural Equation Modeling was the statistical technique employed in the study. Findings revealed that socioeconomic disadvantage remains a primary contributor to sentinel health. Indeed the economic growth between 1990 and 2000 was associated with increased rates of sentinel health events. Social disorganization was identified as a primary contributor to sentinel health events at a specific time point (2000), but was not significant over time (1990 -2000). Conversely, the inadequacy of health care resources was non-significant in the cross-sectional model (2000), but significant in the longitudinal model (1990 -2000). In both models, racial characteristics were fundamentally linked to ecological predictors of health We found support for the notion that sentinel health events would be reduced through economic equity and the development of healthy environments where community ties are reinforced. Less support is found for saturating given geographical areas with health care resources in order to reduce sentinel health events. Future research should be directed by the theoretical advancements made by this study. More specifically, future studies should examine independent cross-level effects, that is, through the inclusion of behavior variables as mediating factors for ecological constructs.


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Graduation Date





Wan, Thomas


Doctor of Philosophy (Ph.D.)


College of Health and Public Affairs

Degree Program

Public Affairs








Release Date

May 2007

Length of Campus-only Access


Access Status

Masters Thesis (Open Access)