Social Determinants of Health Community Pilots

In 2020, the Centers for Disease Control and Prevention (CDC) awarded funds to the Association of State and Territorial Health Officials (ASTHO) and National Association of City and County Health Officials (NACCHO) to assess the work of multi-sector coalitions to advance health equity by addressing social determinants of health (SDOH).

ASTHO and NACCHO selected 42 community multi-sector partnerships from across the country as a part of the Improving Social Determinants of Health–Getting Further Faster (GFF) pilot project. In partnership with RTI, they conducted a national retrospective evaluation.

Year 1 Evaluation

Highlights of the evaluation findings for year 1 of the project were:

  • All 42 GFF partnerships built community capacity for addressing SDOH through new or strengthened partnerships, data and data systems, or strategic plans; leveraged resources; or engaged residents. Forty-one partnerships involved state or local health departments.
  • 90% of GFF partnerships contributed to community changes that promote healthy living, such as building new walking trails, bike lanes, and playgrounds; creating new community and school gardens; and adopting tobacco-free policies.
  • More than half of GFF partnerships reported positive health outcomes data for their SDOH initiatives, including improved health behaviors, clinical outcomes, and overall health and wellness, and decreased health care use and costs.
  • A modeling analysis of 29 partnerships’ SDOH initiatives suggested promising long-term impacts over a 5-, 10-, and 20-year time frame.

See the brief evaluation report pdf icon[PDF – 974 KB] for year 1. For the full year 1 report please email the Office of Policy, Planning and Partnerships. See the Community Pilots recipients.

Coalition Highlights

Built Environment Success

West Louisville Outdoor Recreation Initiative’s infrastructure improvements and outdoor educational and recreational programming: Infrastructure investments included park amenities that expand youth outdoor educational and recreational programming and use of outdoor spaces by the community. Physical activity increased among participants in park programs. Of 128 participants, 60 completed pre-post surveys, which showed a significant increase in the number of days participants got at least 60 minutes of physical activity in 2018.

Community-Clinical Linkages Success

The Diabetes Research, Education, and Action for Minorities (DREAM) Coalition’s Culturally Tailored Community Health Worker (CHW) Intervention: Using a randomized control design, CHWs were embedded into primary care practices and enrolled patients at risk of developing diabetes or with difficulty meeting blood sugar targets into treatment or control groups. Participants in the treatment group received five group educational sessions and two one-on-one visits delivered by a trained CHW, whereas those in the control group received only the first group educational session. The treatment group achieved significant improvements when compared to the control group in physical activity, healthy eating and portion control, weekly blood glucose testing, daily foot checks, and medication adherence (N=127–144).

Food and Nutrition Security Success

Community Builders / Avondale Children Thrive Collaborative’s Health Champions: This coalition coaches mothers to adopt healthy behaviors, including eating healthier foods, attending prenatal appointments, maintaining smoke-free homes, adopting safe sleep practices for babies, and breastfeeding. Health Champions also promote housing stability, facilitate preschool enrollment, and promote early literacy. This initiative is implemented in collaboration with the local health department and a children’s hospital. With reported outcomes in the areas of healthy eating, the program reported that mothers with a Health Champion shop for fresh produce at a mobile market 5 times more than other mothers.

Tobacco-Free Policy Success

Health Promotion Council of Southeastern PA’s Tobacco Dependence Treatment (TDT): TDT programs are offered in a variety of settings to increase cessation integration within worksites, multi-unit housing sites, behavioral health, and community settings to reach populations at higher risk of tobacco use. This coalition was able to improve outcomes in tobacco cessation. An annual average of 1,100 adults receive TDT services from Southeastern Pennsylvania Tobacco Control Providers (SEPA TCP), and 39% of respondents to a 1-month follow-up survey reported not smoking in the past 30 days. Overall, there was a decrease in smoking rates in all but one of the regional counties that TDT was implemented in.

Page last reviewed: January 18, 2022