Social Determinants of Health

Achieving Health Equity by Addressing the Social Determinants of Health

Examples of Our Work

At NCCDPHP, our work is deeply rooted in addressing social determinants of health to reduce barriers and promote health and wellness for all. Some examples of our work and successes are:

Racial and Ethnic Approaches to Community Health (REACH)

The REACH program is one of the only CDC programs that focuses on reducing high rates of chronic diseases for specific racial and ethnic groups in urban, rural, and tribal communities. For over 20 years, the REACH program has funded communities to work with racial and ethnic minorities to reduce tobacco use, improve access to healthy foods, change the built environment to promote physical activity, and connect people to clinical care.

• From 2014 to 2018, in DeKalb County, Georgia, access to healthy food increased for about 242,000 African American residents. As a result, county officials reported a 34% increase in the consumption of fruits and vegetables among customers of farmers’ markets participating in the program.

Healthy Tribes

CDC’s Healthy Tribes partners with American Indian and Alaska Native communities to strengthen cultural connections to improve health, promote wellness, and prevent disease. Healthy Tribes supports three cooperative agreements with 77 awards to tribes and tribal organizations that work synergistically to build public health infrastructure, strengthen chronic disease prevention, and promote wellness with a focus on indigenous culture and cultural connectedness.

• With support from the Healthy Tribes Good Health and Wellness in Indian Country program, the Winnebago Tribe of Nebraska (Ho-Chunk) conducted a food insecurity survey in 2016 revealing that a third of tribal members lacked access to healthy foods. Historically, the Ho-Chunk People were a “planting people” of corn, beans, and squash – the Three Sisters. In conjunction with the US Department of Agriculture, the Little Priest Community College Extension program, Healthy Tribes Tribal Practices for Wellness in Indian Country program, and other partners, the tribe is now working to increase access to traditional foods and food sovereignty. This effort has increased the number of tribal members growing their own food and expanded access to fresh, healthy, locally grown food for purchase on the reservation. In 2020, 80 family gardens were established, and farmers’ market produce has been distributed weekly to families across the reservation.

Well-Integrated Screening and Education for Women (WISEWOMAN)

WISEWOMAN screens low-income women aged 40 to 64 for heart disease risk factors and refers them to community resources that can help them control their blood pressure, eat a healthier diet, be more physically active, and quit smoking.

• From 2014 to 2018, the Utah WISEWOMAN program provided 17,435 heart disease and stroke risk factor screenings to 10,537 women. It also provided 41,405 healthy behavior support services. A total of 674 women who were previously undiagnosed learned that they had high blood pressure and were referred for treatment.

National Breast and Cervical Cancer Early Detection Program (NBCCEDP)

The NBCCEDP helps low-income women with little or no health insurance gain access to timely breast and cervical cancer screening, diagnostic, and treatment services.

• The Illinois Breast and Cervical Cancer Program (IBCCP) and the state of Illinois offer breast and cervical cancer screening and diagnostic tests to uninsured or underinsured women in the state. In 2017, IBCCP started the Community Navigation Pilot (the Pilot) to to link the community to these services. The Pilot funds seven IBCCP lead agencies to hire and sustain community navigators, implement evidence-based interventions for funded services, partner with local community agencies to help with social media outreach, and increase awareness and enrollment of non-Hispanic Black and Hispanic women. From 2018 to 2019, caseload totals increased 341% for Hispanic women, 95% for non-Hispanic Black women, and 35% for non-Hispanic White women.

National Tobacco Control Program (NTCP)

The NTCP encourages coordinated national efforts to reduce tobacco-related diseases and deaths by eliminating exposure to secondhand smoke, promoting quitting among adults and youth, preventing initiation among youth and young adults, and identifying and eliminating tobacco-related disparities.

• The National Alliance for Hispanic Health’s Nuestras Voces (Our Voices) National Network, a CDC-funded initiative, helps Hispanic communities to decrease tobacco use and secondhand smoke exposure, increase cancer prevention strategies, and improve disease management. Nuestras Voces used the Alliance’s Su Familia helpline to provide tailored answers to health concerns, connect callers to local services, and help them navigate the health care system. During 2014–2018, the helpline served 2,739 Hispanic callers nationally with tobacco or cancer-related issues by referring them to the Spanish-language quitline, Déjelo Ya, and to local health care services. During 2014–2016, Su Familia helped another 3,138 Hispanic callers with tobacco cessation counseling services and cancer information and referrals.

National Diabetes Prevention Program

Scaling the National Diabetes Prevention Program (National DPP) in Underserved Areas expands access to the National DPP lifestyle change program to increase enrollment of men, Medicare beneficiaries, African Americans, Asian Americans, Hispanics, American Indians, Alaska Natives, Pacific Islanders, and people with visual impairments or physical disabilities.

• Using a faith-based approach, The Balm in Gilead established the Southeast Diabetes Faith Initiative (SDFI), a partnership of historically black church denominations in five states in the Southeastern U.S., to expand access and utilization of the National Diabetes Prevention Program (National DPP). The goal of this multi-faceted initiative is to create a sustainable infrastructure within faith-based institutions to effectively deliver the National DPP lifestyle change program to underserved communities in Alabama, Georgia, North Carolina, South Carolina and Virginia. As of 2020, SDFI has enrolled over 1,100 participants, of which more than 60% were African American, in the National DPP.