Public Health Groups Invest in National Evaluation of Social Determinants of Health

February 10, 2021

ARLINGTON, VA—The Association of State and Territorial Health Officials (ASTHO) and the National Association of County and City Health Officials (NACCHO) have selected 42 community multi-sector partnerships/coalitions across the country to receive over $2 million as a part of the Improving Social Determinants of Health – Getting Further Faster pilot project.

Selected communities have a demonstrated impact in advancing health equity by addressing social determinants of health and will participate in a national retrospective evaluation to understand the impact of recent social determinants of health (SDoH) experiences and highlight successful strategies. The SDoH are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.

The national evaluation focuses on five areas of SDoH directly linked to chronic disease:

  • Built Environment: Human-made surroundings that influence overall community health and individual behaviors that drive health.
  • Community-Clinical Linkages: Connections made among health care systems and services, public health agencies, and community-based organizations to improve population health.
  • Food Insecurity: An economic and social condition characterized by limited or uncertain access to adequate and nutritious food.
  • Social Connectedness: The degree to which individuals or groups of individuals have and perceive a desired number, quality, and diversity of relationships that create a sense of belonging and being cared for, valued, and supported.
  • Tobacco-Free Policy: Population-based preventive measures to reduce tobacco use and tobacco-related morbidity and mortality.

ASTHO and NACCHO have selected RTI International as the project’s evaluator, and will assess the partnerships’/coalitions’ work and highlight successful strategies and interventions. The evaluation design for this project will be highly participatory and will capture the viewpoints and experiences of the selected communities. A final report and supporting resources will be made available publicly later this year.

“This project is a significant step towards establishing policy best practices for social determinants of health,” says ASTHO Chief Medical Officer Marcus Plescia. “We know that addressing these determinants improves community health and saves precious resources. This research will help jurisdictions nationwide move forward with proven, evidence-based policies that create healthier communities.”

“The importance of this initiative cannot be understated. This project will help to advance healthy equity through meaningful, scalable projects that encompass the built environment, food insecurity, social connectedness, and tobacco-free policies, among others. This bold, comprehensive approach to addressing the social determinants will not only benefit the selected communities but will also provide an important platform to share and adopt best practices across the country,” said NACCHO CEO Lori Tremmel Freeman.

Complementary technical assistance will also be provided to the selected coalitions to support their program evaluation, communications, partnership development, health equity, and sustainability efforts related to employing SDoH approaches to improving chronic disease.

The selected partnerships/coalitions and lead organizations are:

  • Access Health Stark County, Inc. – Canton, OH
  • Acenda Integrated Health – Glassboro, NJ
  • ACHIEVE Coalition, Multnomah County Health Department – Portland, OR
  • Active Knox, Knox County Health Department – Knoxville, TN
  • Adirondack Food System Alliance, Adirondack Health Institute – Glens Fall, NY
  • Allies in Caring, Inc., The Hammonton Health Coalition – Hammonton, NJ
  • Asian American Center of Frederick – Frederick, MD
  • Avondale Children Thrive Collaborative, The Community Builders – Cincinnati, OH
  • Be Well™ Baytown, University of Texas MD Anderson Cancer Center – Houston, TX
  • BPSOS Center for Community Advancement – Westminster, CA
  • Buffalo Tobacco Action, Cicatelli Associates, Inc – Buffalo, NY
  • Central Lincoln County YMCA, Lincoln Health CLC YMCA – Damariscotta, ME
  • Centura Health Food Security Coalition, Centura Health & Jefferson County Public Health – Jefferson County, CO
  • Community Connections, Reading Hospital – Reading, PA
  • Community Resource Hubs, Atlanta Regional Collaborative for Health Improvement (ARCHI) – Atlanta, GA
  • The DREAM (Diabetes Research, Education, and Action for Minorities) Initiative, Council of Peoples Organization – New York, NY
  • Food as Medicine Collaborative, San Francisco Department of Public Health – San Francisco, CA
  • Health by Design – Indianapolis, IN
  • Healthy Here Coalition, Presbyterian Healthcare Services – Albuquerque, NM
  • Healthy Klamath Coalition, Blue Zones Project – Klamath Falls, OR
  • Healthy Little Havana – Miami, FL
  • Health Promotion Council, Southeastern PA Tobacco Control Project – Philadelphia, PA
  • IMPACT, AllianceChicago – Chicago, IL
  • Invest Health Roseville – Roseville, CA
  • Lancaster County Health and Wellness Commission, Upper Midlands Rural Health Network – Lancaster, SC
  • Lead Prevention Team, Afghan Health Initiative – South King County, WA
  • Live Well Allegheny REACH Coalition, Allegheny County Health Department – Allegheny County, PA
  • Louisiana Healthy Communities Coalition, Louisiana Cancer Prevention and Control Programs – New Orleans, LA
  • Maryland Living Well Center of Excellence – Salisbury, MD
  • Massachusetts Municipal Wellness and Leadership Initiative, Metropolitan Area Planning Council – Boston, MA
  • National Urban American Indian and Alaska Native Cancer Coalition, American Indian Cancer Foundation – Minneapolis, MN
  • Nevada Tobacco Prevention Coalition, Smoke-Free Truckee Meadows – Reno, NV
  • Newport Health Equity Zone, Women’s Resource Center – Newport, RI
  • Ogden Civic Action Network, Weber State University – Ogden, UT
  • Proviso Partners for Health – Maywood, IL
  • Staten Island Child Wellness Initiative, Staten Island Partnership for Community Wellness – State Island, NY
  • Supports for Healthy Aging in Rural New York, Rural Health Network of SCNY – Broome County, NY
  • Sussex County Health Coalition – Georgetown, DE
  • Tobacco Free Volusia, FL Department of Health in Volusia County – Daytona Beach, FL
  • Trenton Health Team – Trenton, NJ
  • Westside Connect, Chris 180 – Atlanta, GA
  • West Louisville Outdoor Recreation Initiative, Wilderness Louisville, Inc – Louisville, KY

CDC’s National Center for Chronic Disease Prevention and Health Promotion awarded funds for this pilot project through the Strengthening Public Health Systems and Services Through National Partnerships (CDC-RFA-OT18-1802) cooperative agreement. The purposes of the cooperative agreement are to strengthen the nation’s public health infrastructure; ensure a competent, current, and connected public health system; and improve the delivery of the 10 essential public health services.


ASTHO is the national nonprofit organization representing the public health agencies of the United States, the U.S. territories and freely associated states, and Washington, D.C., as well as the more than 100,000 public health professionals these agencies employ. ASTHO members, the chief health officials of these jurisdictions, are dedicated to formulating and influencing sound public health policy and to ensuring excellence in public health practice.

The National Association of County and City Health Officials (NACCHO) represents the nation’s nearly 3,000 local health departments. These city, county, metropolitan, district, and tribal departments work every day to protect and promote health and well-being for all people in their communities. For more information about NACCHO, please visit