Social and Structural Determinants of Health and Incidence Rates of Sexually Transmitted Diseases

Abstract

Background: The United States (U.S.) faces a severe sexually transmitted disease (STD) epidemic, with rates exceeding historical highs. Social determinants of health (SDOH), LHD’s STD-related service delivery and local health department (LHD) resources influence STD incidence rates. Current STD prevention approaches often focus on individual-level behavior change, neglecting the crucial role of community-level factors. This dissertation addresses this research gap by exploring the links between SDOH, LHD’s STD-related service delivery, and STD incidence rates at the county level.Purpose: Building on a robust conceptual framework, the aims of this dissertation were to (1) evaluate the longitudinal associations between social determinants of health and STD incidence rates at the county-level in the U.S.; (2) investigate the impact of differences in STD-related screening service delivery on STD incidence rates; and (3) identify positive deviant (PD) counties that have exceptionally low STD rates and examine the predictors of STD outcomes in those counties. Methods: This dissertation utilized various quantitative methods, including a panel regression model, a spatial autoregressive model, and PD analysis, to analyze data from publicly available sources. Results: Aim 1 found that STD incidence rates, including chlamydia, gonorrhea, and P & S syphilis, more than doubled over a 20-year period. Longitudinal analyses revealed significant associations between higher social capital and lower chlamydia and gonorrhea rates. Higher eviction rates correlated with increased STD incidence across all three STDs, while higher prison incarceration rates were associated with higher gonorrhea rates. Aim 2 indicated that LHD jurisdictions relying on STD-related screening services, community-delivered and independent of LHD funding, demonstrated significantly lower STD incidence rates compared to those with STD-related screening services provided by LHDs directly and by others in the community. Aim 3 found that 19.06% of U.S. counties were classified as PD counties, exhibiting unexpectedly low STD incidence rates. Predictors of PD counties included small population sizes, and specific social vulnerability index (SVI) subcategories related to racial and ethnic subgroups, housing and transportation vulnerabilities. Counties providing STD-related treatment services provided LHD directly and through community providers were associated with PD identification. Conclusions: The dissertation contributes to the understanding of the complex relationships between SDOH, STD-related service delivery approaches, and STD incidence rates. Our findings can inform policy makers and public health officials in developing targeted interventions and allocating resources to reduce STD rates. The identification of PD counties provides valuable insights into potential best practices for STD prevention and control.