SOCIAL DETERMINANTS OF HEALTH 
in Western North Carolina

What are social determinants, and why are they critical to the health of western North Carolina?

Social determinants of health are "the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems."

(World Health Organization, 2019)

Some environmental conditions enhance quality of life and positively influence population health outcomes. 

Examples of these conditions include: “safe and affordable housing, access to education, public safety, availability of healthy foods, local emergency/ health services, and environments free of life-threatening toxins."

(Healthy People 2020, 2018)

These social and environmental conditions contribute significantly to health outcomes. In fact, research suggests that up to 80 percent of patient health outcomes are determined by social and environmental factors, rather than clinical care.

(Magnan, 2017)


The number of deaths that can be linked to poverty, racism, and other social factors is comparable to leading causes of death in the US, such as heart attacks, stroke, and lung cancer. 

(Galea, Tracy, Hoggart, DiMaggio, and Karpati, 2011) 

Healthy People 2020 highlights the importance of addressing Social Determinants of Health by including “create social and physical environments that promote good health for all” as one of the four overarching goals for the decade.

(CDC, 2019)

What do the numbers say?

Explore the regional WNC Data Set to review local and regional poverty data in more depth.

“The ongoing stress and challenges associated with poverty can lead to cumulative health damage, both physical and mental.” 

County Health Rankings and Roadmaps, 2019

Poverty disproportionately impacts our youngest residents. 

Almost a quarter of children (22.7%) under the age of 18 in WNC were living below poverty level in 2013-2017. 

(ACS, 2019)

"While repercussions resulting from poverty are present at all ages, children in poverty may experience lasting effects on academic achievement, health, and income into adulthood. 

Low-income children have an increased risk of injuries from accidents and physical abuse and are susceptible to more frequent and severe chronic conditions and their complications such as asthma, obesity, diabetes, ADHD, behavior disorders, and anxiety than children living in high income households."

(County Health Rankings and Roadmaps, 2019) 

Adverse Childhood Experiences, or ACEs, also can impact children's health into adulthood. Chronic stressful or traumatic childhood experiences can alter brain development and the immune system, leading to lasting physiological and cognitive changes. 

A large and growing body of evidence shows that ACEs have a significant negative effect on a broad range of cognitive, socio-emotional, and health outcomes over the lifespan, including risk for chronic disease, mental illness, violence, and being a victim of violence. 

North Carolina Social Determinants of Health by Regions

The North Carolina Department of Health and Human Services’ State Center for Health Statistics has created an interactive map with a series of overlays showing social determinants of health indicators in North Carolina, including the economic, social and neighborhood, and housing and transportation status of residents across the state.

(NC DHHS, 2018)

Food Insecurity, Housing Instability, Transportation Challenges, and Interpersonal Violence and Toxic Stress

The North Carolina Department of Health and Human Services, in collaboration with stakeholders, identified four priority domains of Social Determinants of Health: 

1) Food Insecurity
2) Housing Instability
3) Transportation Challenges
4) Interpersonal Violence and Toxic Stress

These conditions not only have a deep impact on a person’s health, safety and well-being, but also on healthcare utilization and costs.

(NC DHHS, 2018)

Now, let's explore each of these four domains in western North Carolina...

Food Insecurity

Three in five very low-income adults in WNC have experienced food insecurity in the past year. 

(WNCHN – WNC Healthy Impact Community Health Survey, 2018)

Food Insecure represents those who responded "often true or sometimes true" to either: 1) Worried about whether our food would run out before we got money to buy more or 2) The food we bought just did not last, and we did not have enough money to get more. 

Approximately 25% of adults are food insecure in WNC. 

The following adult populations were significantly more likely to be food insecure in 2018:

   - Women (27.4%)

   - Adults aged 18-39 (37.4%)

   - Very low (60.3%) and low income (38.9%)

   - Those identifying as either AI/AN (Native American) (37.1%) or  Hispanic (39.6%)

(WNCHN – WNC Healthy Impact Community Health Survey, 2018)

Differences in health outcomes across social groups, economic status, and racial/ethnic identity are closely linked with disparities in social determinants of health, which disproportionately burden individuals and communities who experience systemic disadvantage and/or discrimination.

The items below are paraphrased themes that emerged from a 2018 regional survey of key informants. These responses do not:

• Necessarily reflect accurate or scientifically validated information about health determinants, outcomes, and/or strategies for change,

• Represent an exhaustive list of factors that can help or hurt efforts to address this key regional health issue.

"Agencies are collaborating to meet existing food needs. Desire to help exists and the community is supportive."

(WNCHN - Online Key Informant Survey, 2018)

"We need a better distribution system, as well as a variety of food choices and sharing of knowledge so that people may supplement their diet with locally grown food."

(WNCHN - Online Key Informant Survey, 2018)

The information in this section should be interpreted and used with care. It should be used only to help local health departments and agencies begin to understand community perceptions about local health issues. Communities are strongly encouraged to collect their own, local-level data to inform local planning and evaluation activities.

Housing Instability

Click on the counties or years listed in "Change Filter" on top of the chart to select which counties and/ or years you want to view.

Approximately, twenty percent (19.7%) of households are severely rent burdened (Units Spending >50% Household Income on Housing) in WNC in 2013-2017. 

(ACS, 2019)

Thirty percent of household income is a widely used and accepted standard to measure the extent of housing affordability problems across the country.

(Joint Center for Housing Studies of Harvard University, 2018)

Mapping Housing Affordability in North Carolina

The North Carolina Housing Coalition has developed a mapping tool in partnership with the North Carolina State University Geospatial Information Science and Technology Program. This tool explores different aspects of the housing affordability challenge faced by each county.

(North Carolina Housing Coalition, 2019)

Explore the 2019 County Profiles for additional county-level housing data, including: a comparison of what different jobs pay and changes in home prices, foreclosures, and rental options in communities. 

The items below are paraphrased themes that emerged from a 2018 regional survey of key informants. These responses do not:

• Necessarily reflect accurate or scientifically validated information about health determinants, outcomes, and/or strategies for change,

• Represent an exhaustive list of factors that can help or hurt efforts to address this key regional health issue.

"The most important thing that has happened so far is simply the realization of the need."

(WNCHN - Online Key Informant Survey, 2018)

"New housing is expensive and not affordable for low-income and seniors."

(WNCHN - Online Key Informant Survey, 2018)

The information in this section should be interpreted and used with care. It should be used only to help local health departments and agencies begin to understand community perceptions about local health issues. Communities are strongly encouraged to collect their own, local-level data to inform local planning and evaluation activities.

Transportation Challenges

A total of 17,116 or 5% of occupied households (includes owner and renter occupied units) did not have access to a vehicle in 2013-2017. 

(ACS, 2019)

“Because transportation touches many aspects of a person’s life, adequate and reliable transportation services are fundamental to healthy communities.”

(American Hospital Association, 2017)

The items below are paraphrased themes that emerged from a 2018 regional survey of key informants. These responses do not:

• Necessarily reflect accurate or scientifically validated information about health determinants, outcomes, and/or strategies for change,

• Represent an exhaustive list of factors that can help or hurt efforts to address this key regional health issue.

"Growing talks among various community groups about the need of transportation."

(WNCHN - Online Key Informant Survey, 2018)

"Lack of money, lack of a vision for the community and the need for someone/ group to take the lead."

(WNCHN - Online Key Informant Survey, 2018)

The information in this section should be interpreted and used with care. It should be used only to help local health departments and agencies begin to understand community perceptions about local health issues. Communities are strongly encouraged to collect their own, local-level data to inform local planning and evaluation activities.

Interpersonal Violence and Toxic Stress

"Interpersonal violence refers to violence between individuals, and is subdivided into family and intimate partner violence and community violence. [Family and intimate partner violence] includes child maltreatment; intimate partner violence; and elder abuse, while [community violence] is broken down into acquaintance and stranger violence and includes youth violence; assault by strangers; violence related to property crimes; and violence in workplaces and other institutions."

World Health Organization, 2019

The NC Council for Women and Youth Involvement (NCCFWYI) requires each state-funded domestic violence (DV) grantee to report semi-annually on client service provision. The above chart represents the number of crisis calls made to state-funded domestic violence agencies in WNC per fiscal year. 

An average of 7,069 persons per year in the WNC region were victims of domestic violence over the period 2014-2015 through 2017-2018. 

There was a decrease in the number of crisis calls answered and clients served in WNC from fiscal year 2017 to 2018.

(North Carolina Department of Administration, 2019)

Sexual assault is often under-reported. Approximately, 230 out of every 1,000 sexual assaults are reported to the police, meaning about 3 out of 4 go unreported. 

Department of Justice - National Crime Victimization Survey, 2017

The items below are paraphrased themes that emerged from a 2018 regional survey of key informants. These responses do not:

• Necessarily reflect accurate or scientifically validated information about health determinants, outcomes, and/or strategies for change,

• Represent an exhaustive list of factors that can help or hurt efforts to address this key regional health issue.

"Empowering more women, and educating both men and women."

(WNCHN - Online Key Informant Survey, 2018)

"There is still a high degree of shame in being victimized. That is changing, but progress still must be made."

(WNCHN - Online Key Informant Survey, 2018)

The information in this section should be interpreted and used with care. It should be used only to help local health departments and agencies begin to understand community perceptions about local health issues. Communities are strongly encouraged to collect their own, local-level data to inform local planning and evaluation activities.

How is the region prioritizing social determinants of health?

The western North Carolina region includes 17 communities: 16 counties and Eastern Band of Cherokee Indians (EBCI)

In the 2018 CHA cycle, two communities selected social determinants of health as a key priority.

However, all WNC communities consider the social determinants of health as key drivers to addressing local key health priorities.

Learn more about how counties in western North Carolina work to determine their local community health priorities by watching the video (right). 

Navigating services like health, housing, employment, and transportation can be incredibly difficult, but these factors all contribute to our overall health.

NCCARE360 provides the opportunity for health to all North Carolinians by providing public access to resources and helping health and community-based organizations make electronic referrals, communicate in real time, securely share client information, and track outcomes together.

The regional dataset (WNC Healthy Impact Community Health Survey and Online Key Informant Survey) is available thanks to contributions from hospitals in the 16-county region of western North Carolina. Thank you!