We  facilitated several community partnership development meetings and health and wellness workshops in each of the four target cities. In preparation for the community workshops, we held community partnership development meetings to listen to local stakeholders identify their most pressing social determinants.  Local health influencers, advocates and community stakeholders attended these meetings. These preparatory meetings enabled a collaborative planning process by which community stakeholders helped project team members with the development of an agenda and discussion materials for the workshop.

At the health and wellness workshops, we presented our findings (including identifying each city's highest health risks), conducted trainings on how to use the data dashboard and storymap visualizations tools and facilitated discussion around the systemic causes and evidence-based policy interventions for areas of concern. Attendees from the community partnership development meetings participated on the panels at the workshops in each city. At the end of the workshops, each participant stated their intent to use the data, addressed the social determinants of health they face in their work and collaborated with other workshop participants to identify solutions.


All the participating cities had some level of collaboration amongst health care providers, health promotion and public health organizations, social and community services and community planning and development entities. Many of the participants knew each other prior to the workshop, but collaboration had been relatively informal, reactive, or occasionally an intentional one-off joint initiative. Nonetheless, many new intersectoral connections were made at the workshops.

One common type of connection included community development and social service organizations learning about health system community health needs assessments (CHNAs) and identifying common goals. Another frequent connection was between agencies that served or housed a particular population, by where participants learned about other organizations that were interested in providing health services that had previously been lacking. A third type of common connection was between community and academic partners, identifying opportunities to research issues, review evidence-based policy and programs and use student program practice requirements to advance community health objectives. Overall, there was interest in more systemic partnerships, potentially coordinated through the needs assessment and strategic planning activities conducted by health departments, city planning and development departments and the CHNA process.

Obesity, chronic disease, asthma, mental health, child development are common health concerns across all cities. Poverty, employment and benefits, education, housing and homelessness, and transportation are also common social and economic concerns across all cities. There is widespread concern about structural or persistent disparities. For instance, where do you begin helping families with few resources and a lot of health needs? Also, the awareness of persistent disparities contribute to the stigmas which prevents solutions.

A recurring question was whether these issues could be solved in a generation. Other questions include can big changes be made now that will help today’s kids become healthy adults and what does it mean for the future if there are major gaps in quality child care, parents with mental illness, and kids who aren’t getting adequate health care or developmental support.

Albany Workshop

A community partnership development meeting was held in Albany in January 2019, followed by the health and wellness workshop in February.

Albany faces severe health burdens and inequities and is working with limited resources to address them. The major local hospital is particularly concerned with chronic disease and ER utilization.

Some of their main social determinants of health (SDOH) concerns are about car-less and single parent households. They want to find out what high disease rates and health disparities are costing the city.

They currently use the Healthy Communities Institute dashboard and a case heat map to prioritize issues. The 500 Cities data will enhance this effort. They are working on community development and health collaboration initiatives.

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Atlanta Workshop

Between June 2018 and January 2019, we connected with the community at outdoor festivals, community health events and neighborhood meetings. We introduced the project, talked directly with and listened to numerous stakeholders, and invited them to the workshop. We then held the Atlanta health and wellness workshop in February 2019.

The majority of attendees had attended prior Atlanta Regional Collaborative for Health Improvement (ARCHI) events where they had learned about health inequities and SDOH, given many of them an awareness Atlanta’s institutional health and social inequities spatial patterns.

The workshop introduced attendees to the data and them time for exploration of the visualization tools. This was followed by a conversation around community-driven research and interventions to encourage participants to explore the 500 Cities data with the communities they served. Participants were very interested in linking the 500 Cities data to other data sources they used in their community development and health services work.


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Columbus Workshop

A community partnership development meeting was held in Columbus in November 2018, followed by the full workshop in January 2019. We returned to Columbus, twice in February, to conduct a presentation for the city’s Department Directors and the City Manager and a led a lunch and learn meeting with community residents.

Participants in the workshop discussed how to integrate the 500 Cities data with other data they use, such as Kids Count, GEEARS child development indicators, birth outcomes, transportation and clinics. Some of their main concerns were how interventions should vary by SDOH risk factors. They were also concerned whether the local community development organizations and agencies are addressing the highest health risks as identified by the 500 Cities data.  If not, then what are ways to better coordinate the agencies.

The local university, Columbus State University, shared information about their nursing program generating new providers each year and their health sciences program has 70 practicum placements each year who could put be placed with these community partners.

The workshop participants outlined their priorities as: get policy makers more aware and empathetic towards SDOH, develop a broader approach to transportation alternatives that are sustainable and equitable, build more partnerships by connecting with non-traditional sectors and secure more funding for health care research.

During the community partnership development meeting, the city’s major hospital shared that they were currently conducting their CHNA process and were interested in using the 500 Cities data for the assessment. Their priorities are diabetes and cancer and they were enthused  about the ability to view the spatial patterns using the visualization tools.

At the presentation for the city of Columbus’ directors, the staff and City manager found that the 500 Cities data and our SDOH approach could be of value to the city’s economic development and wellness initiatives. The health issues we highlighted as high prevalence were the same ones the majority of employees on the city insurance program are receiving treatment for and they see these as community wide issues.

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Savannah Workshop

A community partnership development meeting was held in Savannah in October 2018, followed by the full workshop in November.

Participants were particularly concerned about homelessness and low-quality child care. Knowing that education is an important predictor of future health status, they were concerned that lack of quality early child development supports might forecast issues with adult unemployment, poverty, and poor health outcomes.

The Healthy Savannah group and the Coastal Georgia Indicators Coalition are bringing significant coalitions together to address community health determinants. They are also participating in the Invest Health national initiative.

Participants were excited about their future opportunities through intersectoral collaboration and for bringing a health equity focus into their work.

Download the Savannah PowerPoint!

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We conducted an all-day retreat with selected representatives from each of the four target cities. The retreat focused on receiving feedback on the benefits and advantages of using the 500 Cities data to address critical needs and service gaps in rural and/or underrepresented communities and recommendations for future projects using the 500 Cities data.

We believe the feedback from the retreat attendees offers better insight to how the 500 Cities data and our visualization tools help with their current work and future endeavors with improving health outcomes.

Question 1: What are the benefits and advantages of using the 500 Cities data to address critical needs and service gaps in rural and/or underrepresented communities?

  • Helps the community to tell our health care and needs story.
  • Helps Identify health and social conditions inherent in communities.
  • Identifies community challenges unseen and not recognized.
  • Allows community dialogue at a wider scale to generate community support and build consensus for decisions.
  • Problem areas are clearly identified and can compare with other communities.
  • Helps to educate decision makers by providing better visualizations for each health indicator and risk.
  • Advocacy can take place at the neighborhood level rather than at the county level.
  • Provides data at smaller sample sizes which is more effective in identifying issues in rural/underserved communities.
  • Allows communities to design, scale and deploy resources based on conditions rather than assumptions.
  • Allows communities to view correlations and causal factors.
  • Data can be used for grant applications, advocacy and marketing.
  • Data can help eliminate healthcare funding based on assumptions and perceptions.
  • Layering other data with the 500 Cities data helps with specialized planning efforts like identifying where poor infrastructure may increase health risks.

Question 2: What are recommendations for future projects or initiatives that may incorporate the 500 Cities data with a similar approach?

  • Fund a 5-year project in Georgia to create visualization tools for all Georgia’s large cities, lead collaboration and community engagement efforts across the State and develop a repository for health care policies.
  • Fund additional years of the 500 Cities database. Include smaller cities that are adjacent to the large cities.
  • Develop a training program to teach the public, including librarians, how to use the data to impact community programs and grants.
  • Develop a training program to teach advocacy organizations how to use the data to influence public policy and legislation.
  • Work with the Department of Defense for the inclusion of military persons health data. This is helpful to those communities with military installations.
  • Fund the development of visualization tools which incorporate local data based on local community needs.
  • Conduct on the ground surveys of community assets where high risk areas are identified.
  • Examine the role of philanthropy in providing complimentary services for collaborators in high risk communities.
  • Develop tools to assist with strengthening local hospitals’ community health needs assessments.
  • Include trending data such as opioid data in the 500 Cities dataset.
  • Fund projects to encourage local and state health care agencies to share data.


Multiple representatives, from over 145 organizations, participated in the community partnership development meetings and health and wellness workshops. Participants represented local neighborhoods, nonprofit and community health advocacy organizations, local, State, and Federal government agencies, healthcare, housing, religious, mental health and environmental groups, universities and colleges, and small and large businesses.

32nd Street Media

AAPHC Rural Model Clinic

Albany Area Primary Health Care Rural Clinic

Albany Housing Authority

Albany State University

Andrew College

Aspire BHDD

Aspire Georgia Recovery Project

Atlanta Humane Society

Atlanta Neighborhood Development Partnership (ANDP)

Atlanta Regional Collaborative for Health Improvement

Atlanta Regional Commission

Atlanta Relay Bike Share

Atlanta Volunteer Lawyers Foundation

Beyond the Bell

Big Brothers Big Sisters


Carter Center, Emory Fuqua Center for Late Life Depression

CCHD/Safety Net

Center for Victims of Torture

Chatham County Dept. of Public Health

Chatham County Public Health Department

Chatham County Safety Net Planning Council

Chatham County Strategic Planning office

Chatham Family Connection Collaborative

CHRIS 180 (CHRIS Kids, Inc.)

City of Albany

City of Albany Recreation & Parks

City of Atlanta

City of Savannah

Clinical Research Pathways

Coastal Georgia Indicators Coalition

Columbus Consolidated Government

Columbus Consolidated Government - Planning Department

Columbus Family Connection

Columbus State University

Columbus State University - Turner College of Business

Community Development Banking

Community Foundation for Greater Atlanta

Community Housing Capital


DCSS/ESP Parent Mentor

DeKalb County Commission, District 2

Department of Public Health - Columbus Health Department

Dougherty County School System

Emmaus House

Emory Clinic

Emory School of Medicine

Emory University

Emory University Hospital - Midtown

Enterprise Community Partners


Family Literacy Connection

Federal Reserve Bank of Atlanta

Fulton County | Health & Wellness

GA Alliance for Health Literacy

Garden City United Methodist Church

Gateway BHS

Gateway Center

Geogia Southern University - Dept of MHA

Georgia Center for Nonprofits

Georgia Department of Community Affairs

Georgia Family Connection Partnership

Georgia Global Health Alliance

Georgia Health Information Management Association

Georgia Health Policy Center

Georgia Organics

Georgia Public Health

Georgia Recovery Project

Georgia Southern University – Armstrong

Georgia Southern University - Statesboro

Georgia State University

Georgia Tech

Georgia Vocational Rehabilitation Agency

Georgia Watch

Georgians for a Healthy Future

Girls Inc. of Columbus and Phenix-Russell

Global Health Action

Good Advisors

Grady Medical Hospital

Greenbriar CC


Healing Community Center

Health Restoration 101

Healthy Savannah

Historic Westside Gardens ATL, Inc.

Horizons Community Solutions

House of TIME

Housing Authority od Dekalb County

Job Corps

Kaiser Permanente of Georgia

Karna LLC


Map International

Med Bank

Mental Health America of Georgia

Mercer University

Mercy Care

Mercy Medical

MercyMed of Columbus

Mixed Greens

Morehouse School of Medicine

Neighborhood Nexus


Odyssey Family Counseling Center

Parent University

Partnership of Southern Equity

Peach State Health Plan

Phoebe Putney Health Systems- Network of Trust School

Phoebe Putney Memorial Hospital

Piedmont Columbus Regional

Quest For Change, Inc.

Howard Dobbs, Jr. Foundation

River Valley Area Agency on Aging

Ruby A. Neeson Diabetes Awareness Foundation, Inc.

S & S Private Health Care

SA Public Health Solutions, LLC

Sadie G Mayes Health & Rehabilitation Center

Savannah State University

Savannah-Chatham County Public Schools


SJCHS - St. Mary's Health Center

Southeast Energy Efficiency Alliance

Southwest Georgia Public Health

St. Francis Hospital

St. Joseph's Health System/ Mercy Care

St. Mary's Hospital

State of Georgia Dept. of Community Support

State of Georgia Dept. of Public Health

Step Up


The Fulton-DeKalb Hospital Authority

The Hughston Foundation



United Way of Coastal Empire

United Way of Columbus

United Way of Greater Atlanta

United Way of Southwest Georgia

United Way of the Chattahoochee Valley

Univ. of Georgia-Chatham County Extension

Univ. of Georgia-Dougherty County Extension

Urban Health Initiative - Emory University

Valley Healthcare System, Inc.

Wellcare Health Plans, Inc.

WellStar Atlanta Medical Center South

West Central Health District-Georgia Dept. of Public Health

This research is based upon work supported by the Urban Institute through funds provided by the Robert Wood Johnson Foundation. We thank them for their support but acknowledge that the findings and conclusions presented in this report are those of the author(s) alone, and do not necessarily reflect the opinions of the Urban Institute or the Robert Wood Johnson Foundation.