Social Determinants of Health and Healthy People
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NACCHO's partnership with Healthy People 2020 (HP 2020) is designed to support and increase the use of HP 2020 among local health departments (LHDs), non-profit hospitals, and other organizations related to community health assessment and improvement planning. All programmatic activities will be designed to support the HP 2020 ten-year agenda for improving the Nation's health.
With fewer resources and staff, many LHDs face significant challenges in providing essential services that ensure the health and safety of their communities. The HP 2020 approach offers an evidence-based, easy-to-use tool designed to aid LHDs and other organizations in community health assessment work.
The HP 2020-NACCHO Partnership is sponsored by the U.S. Department of Health and Human Services Office of Disease Prevention and Health Promotion.
Below you will find resources to help your department apply HP2020 concepts and address the social determinants of health (SDOH). Find more SDOH resources, including resources to address SDOH in rural communities, on our Addressing Social Determinants of Health in Rural Communities project page.
The Community Health Improvement Matrix (CHIM) was developed to gain a better understanding of the current state of Local Health Department's Community Health Improvement Plans and Non-profit Hospital's Implementation Plans in relation to Social Determinants of Health. Please see the documents below for more information on the CHIM and related resources. The CHIM can facilitate collaboration between local health departments and non-profit hospitals on planning improvement/implementation activities, designating appropriate leads and addressing the social determinants of health.
General sources of SDOH Indicators and data
1. AARP livability indexThe AARP Public Policy Institute promotes development of sound, creative policies to addressour common need for economic security, health care, and quality of life. Their Livability Indexmeasures community livability. Users can search the Index by address, ZIP Code, city, or countyfor livability scores in seven categories for every neighborhood in the US. The Index takes aholistic approach to understanding livability, including the health of residents and the quality ofthe built environment, but also considers engagement, opportunity, and the natural environment.
2. Brookings Institution Metro MonitorThe Brooking Institution Metro Monitor measures the performance of the nation's majormetropolitan economies in three critical areas for economic development: growth, prosperity,and inclusion. In response to increasing income inequality in U.S. cities, inclusive economies arethose that offer opportunities for prosperity across the population. According to the Brookingsmodel, inclusive economies are more equitable, participatory, growing, sustainable, and stable.
4. CDC data set directory of social determinants of health at the local levelThe directory contains an extensive list of existing data sets that can be used to understand socialdeterminants of health. The data sets are organized in 12 categories of the social environment.
5. The Community Indicators ConsortiumThe Community Indicators Consortium advances and supports the development, availability andeffective use of community indicators for making measurable and sustainable improvements inquality of community life. The CIC has an online database of tools for community indicators aswell as communities of practice.
6. County Health Rankings and RoadmapsThe County Health Rankings & Roadmaps program is a collaboration between the Robert WoodJohnson Foundation and the University of Wisconsin Population Health Institute. The annualCounty Health Rankings measure vital health factors, including high school graduation rates,obesity, smoking, unemployment, access to healthy foods, the quality of air and water, income,and teen births in nearly every county in America.
7. US Census BureauUnder the U.S. Census Bureau are a range of surveys, data, and visualization tools for learningabout the U.S. population.Within the Census, the American Community Survey (ACS) is an ongoing national survey ofU.S. households that provides data to guide the distribution of federal funds. You can access datafrom the American Community Survey estimates, released every year in a variety of tables,tools, and analytical reports.
8. NACCHO guide to Resources for Social Determinants of Health Indicators
When thinking about the social determinants of health, there are several perspectives you may take as you pursue data collection for the assessment component of your improvement process. This resource provides a brief description of key steps you may want to consider or take and provides a list of indicators you may want to consider using in your CHA to examine the social determinants of health.
This exercise can be used to assist you in determining if the types of data you have that describe health in your community are indicators of social inequities, institutional power, neighborhood conditions, risk behaviors, disease & injury, or mortality using the BARHII model.
Specialized sources of SDOH Indicators and data
1. AMCHP life course measuresThe Association of Maternal and Child Health Programs (AMCHP) is a national resource,partner and advocate for state public health leaders and others working to improve the health ofwomen, children, youth and families, including those with special health care needs. Through acollaborative process, AMCHP has identified a standardized set of indicators that can be used to measure progress using the life course approach to improve maternal and child health. The final set of 59 indicators is available here, with guidance on measurement.
2. ASCE Report Card for America's InfrastructureThe American Society of Civil Engineers releases a comprehensive assessment of the nation’smajor infrastructure categories. It includes recommendations for raising the grades.
3. Economic Policy InstituteEPI conducts research and analysis on the economic status of low-and middle-income workingAmericans and provides policy recommendations. Their website contains datasets and indicatorson a range of issues affecting workers.
4. Kids Count Data CenterA project of the Annie E. Casey Foundation, KIDS COUNT offers data on hundreds ofindicators related to child and family well-being in the United States. You can download dataand create reports and graphics on the KIDS COUNT Data Center.
The American Planning Association produces knowledge and resources that planners use to make safer, greener, healthier, and more sustainable communities. They offer a list of policy guides for city and regional planning. In particular, the SmartGrowth policy statement advocates for the development of mixed use, mixed income livable communities and provides resources for planning that promotes public health and equity.
2. Healthy People 2020
Healthy People provides science-based, 10-year national objectives for improving the health of all Americans. Their website provides these indicators as well as a collection of evidence-based practices for improving health outcomes.
3. Human Impact Partners
Human Impact Partners aims to increase the consideration of health and equity in decision-making. They offer free tools and resources for conducting a health impact assessment (HIA). They also offer training and technical assistance to build the capacity of impacted communities and their advocates, public agencies, and elected officials to take action on the social
determinants of health and equity.
4. Prevention Institute
The Prevention Institute offers many tools to guide communities in implementing collaborative, effective prevention strategies to create safer, healthier, and more equitable communities. Their guide to health equity metrics is one valuable resource.
5. Public Health Institute
PHI generates and promotes research, leadership and partnerships to build capacity for strong public health policy, programs, systems and practices. PHI hosts the Building Healthy Places Network, which supports collaboration across the health and community development sectors. Their MeasureUp microsite offers resources and tools to help you measure and describe your
programs’ impact on communities and health-related factors.
Community Commons offers “data, tools, and stories to improve communities and inspirechange.” Their Community Health Needs Assessment toolkit has a wealth of resources formapping population demographics for your CHNA, including interactive maps and populationbaseddata reporting tools.
The Community Health Maps blog is a collaborative effort among the National Library ofMedicine, the Center for Public Service Communications, and Bird’s Eye View to provideinformation about low cost mapping tools for community organizations. The blog is meant tosupport both new and experienced GIS mapping users in enhancing their community mappinginitiatives, even if they may be using other tools. The blog contains mapping apps/softwarereviews, best practices, and the experiences of those who have successfully implemented amapping workflow as part of their work.
PolicyMap offers easy-to-use online mapping with data on demographics, real estate, health, jobsand more in communities across the US. With a paid subscription, you can create custommapping tools using your own data and indicators in PolicyMap’s extensive database.
1. Atlanta's Neighborhood Quality of Life & Health Project The Atlanta Neighborhood Quality of Life and Health (NQOLH) Project provides data and analysis to show that the built environment impacts both quality of life and community health at the neighborhood level, making the case for investments in the built environment to improve quality of life and health. NQOLH is an example of a source of free and open data that allows residents, community groups, planners, and policy-makers to assess community needs and develop data-driven planning strategies. The Socioeconomic Conditions (SEC) Index groups Atlanta’s neighborhoods into three categories by community socioeconomic status, given the wealth of research linking SEC to health and quality of life.
2. Bay area regional health inequities initiative (BARHII) The Bay Area regional collaborative is dedicated to advancing health equity. They offers a social determinants of health indicator guide containing 15 SDOH indicator chapters: a table of 72 priority SDOH indicators and their data sources; and technical data appendices. They also have issue briefs on topics such as land use planning, minimum wages, and other topics related to advancing health equity.
3. Socioeconomic hardship index, Chicago Department of Public Health The City of Chicago's Data Portal is dedicated to promoting access to government data and encouraging the development of creative tools to engage and serve Chicago's diverse community. The site hosts over 200 datasets presented about city departments, services, facilities and performance. This dataset contains a selection of six socioeconomic indicators of public health significance and a “hardship index” for the years 2008 – 2012.
4. Virginia Commonwealth University Center on Society and Health The VCU Center on Society and Health in Richmond, VA studies the health implications of social factors such as education, income, community environmental conditions, and public policy. They have several interactive tools and publications demonstrating links between social factors and health.
Below are links to online resources and tools to help LHDs to assess and address social determinants of health through the CHA/CHIP.
NACCHO is continually developing stories from the field abouthealth departments conducting a community health assessment and developing acommunity health improvement plan using Healthy People 2020. Check back oftenas new stories will be posted periodically.
NACCHO Annual2013: Audio-visual clips from five local healthdepartment on the use of Healthy People in community health assessment andimprovement planning. Recorded during NACCHO's 2013 Annual Conference inDallas, voices from Georgia, Florida, Kansas, Kentucky and Montana areincluded.
Plumas CountyPublic Health Agency Collaborative CHA and CHIP: A look athow three hospitals, one local health department, and a tribal health clinic inthis small, rural county are navigating past organizational mistrust, competingpriorities, and strong intra-community identities to examine their community'shealth status and take action to improve health and well-being.
San FranciscoDepartment of Public Health Collaborative CHA and CHIP: Withcollective impact as their primary goal, take a look at how eight hospitals,one local health department, and many other partners are working to identifythe salient issues in their CHNA and taking action to improve the health of SanFranciscans in implementing their CHIP.
Norwalk HealthDepartment Collaborative CHA and CHIP: A look ata strengths-based partnership between the local health department and thehospital in Norwalk, Connecticut, that embodies nearly seamless co-leadershipof a community health improvement process yielding a community health (needs)assessment and CHIP. For this group, their ability to recognize their strengthsand limitations is the foundation of their work.
NACCHO Annual2013 Preconference Session: TheFlorida Department of Health in Miami-Dade County used Healthy People invarious Performance Improvement efforts, including strategic planning, qualityimprovement, accreditation, community health assessment and community healthimprovement planning. Recorded during NACCHO's 2013 Annual Conference inDallas.
Using HealthyPeople 2020 to collaborate on assessment and planning: Alook at the dynamic processes of community engagement and partnership effortsusing the Mobilizing for Action through Planning and Partnerships (MAPP)framework. The Cobb & Douglas Public Health presentation focuses onbuilding strong relationships with schools, organizations, businesses and keydecision-makers in the community to support “Healthier Lives. HealthierCommunities."
Healthy! CapitalCounties Collaborative CHA and CHIP: In theGreater Capital Area of Michigan, three local health departments and fourhospital systems collaborated to complete a regional CHA and CHIP thatemphasized addressing the root causes of poor health outcomes. Here is a lookat how they worked together and how they're moving forward to take action toimprove health.
GallatinCity-County Health Department Collaborative CHA and CHIP: Alook at how a local health department and local hospital in Bozeman, Montanaare working together to apply community health assessment results to improvehealth in a rural and large area in the heart of the Rocky Mountains.
NACCHO Annual2013 Preconference Session: The YellowstoneCounty, MT local health department doing business as Riverstone Health,together with St. Vincent's Healthcare and Billings Clinic, used Healthy Peoplein community health assessment and community health improvement planningactivities for a community with both rural and urban challenges. Recordedduring NACCHO's 2013 Annual Conference in Dallas.
CommunityIndicators Consortium: 2014 IMPACT Summit: Alook at Cuyahoga County’s (Ohio) social justice approach to their collaborativecommunity health improvement process, and how, as a result, they are addressinghealth inequities in the community. – Presentation recorded during theCommunity Indicators Consortium: 2014 IMPACT Summit, Washington, DC.
A look at how one community in Portland,Oregon is collaborating with four local health departments and 14 non-profithospitals to conduct a regional community health needs assessment.
Hospitals,Public Health Creating Community Value: PracticalTools for Moving Into Implementation: Background on Wisconsin (WI)communities are conducting the community health improvement process under theWI statutory requirement for health departments to develop a community healthimprovement plan and process (CHIPP) and an in depth look at two rural countieswhere hospitals and public health are collaborating in their CHIPP efforts.
The reports, webinars, and other tools listed below provide information to help local health departments (LHDs), non-profit hospitals, and other organizations conduct collaborative community health assessment and improvement processes using Healthy People 2020 (HP 2020).
The Community Health Improvement Matrix: an effective tool for implementation planning: These PowerPoint slides are taken from a presentation given at the Association for Community Health Improvement's 2015 Annual meeting. Presenters Barbara Laymon, Lead Program Analyst at NACCHO, Reena Chudgar, Program Analyst at NACCHO and Ed Gerado from Bon Secours Health System. The Healthy People 2020 Social Determinants of Health framework using the Community Health Improvement Matrix is highlighted.
Healthy People 2020: Local Action Leading to Better Health and Well-Being: These PowerPoint slides are from a presentation given by Barbara Laymon, Lead Program Analyst at NACCHO, at the American Public Health Association 2013 Annual meeting. The presentation was part of a session on Healthy People 2020: Addressing social determinants to achieve health equity.
Performance Improvement through Healthy People: These Powerpoint slides outline the application of the Healthy People framework to various aspects of performance improvement, including accreditation, quality improvement, performance management, community health assessment, community health improvement planning and agency strategic planning.
Social Determinants of Health in Community Health Assessment and Improvement Planning: These PowerPoint slides are taken from a presentation given at the Association for Community Health Improvement's 2014 Annual meeting. Presenters Barbara Laymon, Lead Program Analyst at NACCHO and Reena Chudgar, Program Analyst at NACCHO. The Healthy People 2020 Social Determinants of Health framework is highlighted.
Introduction to the Social Determinants of Health and Health Inequities: Click here to access the presentation slides.
Healthy People and MAPP: Survey Findings on Connections, Collaborations, and Challenges: NACCHO surveyed the 434 participants of the Mobilizing for Action through Planning and Partnerships (MAPP) social network site regarding their use of MAPP and HP 2020. This 18-page report describes the current MAPP activity of participants, their views of the impact of MAPP on community health assessment processes and health outcomes, and information regarding the use of HP 2020 within community health assessment activities.
HP2020 in assessment and planning
How To Use Healthy People in Your Assessment and Planning Efforts. Community health assessment and improvement planning can be overwhelming, but HP 2020 can make it easier. NACCHO created a series of short videos, each under three minutes, to showcase how elements of HP 2020 can assist assessment and planning activities. There are five videos total, including topics such as:
Presentation: Identifying Effective Strategies to Address the Social Determinants of Health - This presentation describes the project and PHAB documentation requirements for strategy selection and implementation, discusses what types of actions will best address the root causes of health inequities or social determinants of health, discusses the role of policy change in addressing the social determinants of health, and more.
Archived Webinar: Considering Health Equity in Community Health Improvement Planning
This 60 minute webinar is part of NACCHO''s Performance Improvement Technical Assistance Webinar Series and includes information on the importance of social justice in CHA and CHIP work, types of information necessary for assessing and addressing health inequities, tools for understanding and measuring health inequities as part of a community health improvement process, and more.
- Access the presentation slides.
- Access the webinar notes.
Examining and Addressing the Social Determinants of Health and Health Inequities in CHAs and CHIPs
Training Presentation: Introduction to the Social Determinants of Health and Health Inequities: Click here to access the presentation slides.
Webinar Recording: Considering Health Equity in Community Health Improvement Planning
This 60 minute webinar is part of NACCHO's Performance Improvement Technical Assistance Webinar Series and includes information on the importance of social justice in CHA and CHIP work, types of information necessary for assessing and addressing health inequities, tools for understanding and measuring health inequities as part of a community health improvement process, and more.
- Access the webinar notes.
Recently, NACCHO convenedpartners and leaders from the local, state and national level for a workingmeeting on moving forward community health (needs) assessment and improvementplanning as a field to assure the conditions in which people can be healthy.Materials and resources from the meeting can be found below.
- Forces of Change - Facilitator Instructions
- Forces of Change - Facilitator Schedule and Roles
- Facilitator's Guide: Moving Forward Together to Benefit Our Communities
- Meeting Goals and Objectives
- Greater Norwalk Area Collaborative Community Heath Assessment and Improvement Plan Case Example, Norwalk, CT
- Assuring the Conditions for Population Health: Seeking Collective Impact through Public Health/Primary Care Integration Case Example, Healthy!Capital Counties, MI
- Massachusetts Case Example and ASTHO's Current Activities
- Indiana State Department of Health Case Example
- Maryland Department of Health and Mental Hygiene Case Example
Provisions of the Patient Protection and Affordable Care Act (ACA) require each non-profit hospital facility in the United States to conduct a community health needs assessment (CHNA) and adopt an implementation strategy to meet identified community health needs. In conducting the CHNA, non-profit hospitals are required to take into account input from persons who represent the broad interests of the community served, including those with special knowledge of or expertise in public health.
NACCHO is committed to helping local health departments (LHDs) strategically align their community health assessment efforts with other assessment initiatives such as those of non-profit hospitals. The resources below provide information to help LHDs and non-profit hospitals utilize Healthy People 2020 (HP 2020) to conduct collaborative community health assessment and improvement processes.