NCIPH staff maps social determinants to inform community health improvement

August 26, 2019

Health care providers are increasingly aware that social determinants – the conditions in which people live, work and play – have a far greater impact on community health than the care administered to patients in clinical settings.

When Atrium Health in Charlotte launched its first community health improvement study in 2016, it asked staff at the Gillings School of Global Public Health’s North Carolina Institute for Public Health (NCIPH) to map social indicators of health within its 10-county service area. The resulting online, interactive map helped Atrium partner with Novant Health and the Mecklenburg County Health Department to focus on specific needs within six zip codes. The success of this approach was replicated by the North Carolina Department of Health and Human Services, which has posted an online map of health disparities across the state.

Matt Simon

Matt Simon

Dr. John Wallace

Dr. John Wallace

Applying Data Analytics to Address Social Determinants of Health in Practice,” published in the July-August 2019 North Carolina Medical Journal, details the work of NCIPH’s John W. Wallace, PhD, senior data advisor; Matthew C. Simon, MA, GISP, senior data and geographic information system (GIS) analyst; and Kasey P. Decosimo, MPH, a UNC Gillings alumna and former NCIPH research associate who now works for the United States Department of Veterans Affairs.

The team defined three categories of interest – Social Resources, Economics, and Housing and Transportation – and used U.S. Census and U.S. Department of Agriculture data to map 12 health determinants including education levels, English language ability, access to food and transportation, income, employment, health insurance and housing costs.

“When you put these things on a map, areas light up that have disparities with the rest of the region,” Simon said. “The goal is to put that information out there in a way people can readily grasp, and an interactive map does that pretty effectively.”

Wallace added that the map also “brings people around the table for frank conversations about how they can best use their health improvement efforts and funds to make real differences in the community.” Those conversations, he said, led Atrium and Novant to work together. For instance, both raised their minimum wages when they realized many of their hourly employees lived in impoverished areas.

“What we’ve done with these efforts is only half of the story,” Wallace said. “We recognize we’re not the doers. We’re informing and empowering people to make those changes. That’s what I find rewarding – helping start those conversations so we can work together to reduce inequities.”

Mapping has been important in public health since John Snow traced the 1854 London cholera outbreak, Decosimo said, but this work with geographic informations systems is cutting edge. “Not many people have taken social determinants of health data and built something comprehensive and interactive,” she said. “There is a lot of complexity with that data, but people want to zoom in and see what’s happening in their zip code or at their block level. We were really proud of developing that in collaboration with a large health care system in North Carolina that’s passionate about addressing the issue. It was exciting to engage their leaders with the data.”

Because every member of the mapping team grew up in North Carolina, Decosimo said, this project was especially fulfilling.

“UNC’s School of Public Health is a global entity, so it was extra special for us to be able to give back to our local communities.”

Contact the Gillings School of Global Public Health communications team at


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