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Hackensack Meridian Health's community health project

Courtesy: Hackensack Meridian Health

New Jersey is diverse and densely populated. With approximately 9 million residents spread over 7,350 square miles, there are 1,213 residents per square mile, making New Jersey the most densely populated state in the country, far surpassing the national average of 93 residents per square mile. Northeast counterpart states such as Rhode Island (1,022 residents per square mile), Massachusetts (890) and Connecticut (737) are all less densely populated than New Jersey.2

Health disparities are driven in part by race, ethnicity, geography and socioeconomic status.

Where one lives within the Garden State has a significant impact on one’s health status and health vulnerability. Good or poor health status does not occur independent of one’s environment.

These community and environmental factors are commonly referred to as social determinants of health. Per the World Health Organization, social determinants of health include “the wider set of forces and systems shaping the conditions of daily life.”3 An individual’s economic stability, neighborhood and built environment, education, social structure, access to healthcare, and other aspects of the environment are all social determinants of health.4-7 These measures help to provide a more comprehensive understanding of the ways in which a range of social, economic, and physical factors influence individual health. Social determinants of health most often refer to both economic and social conditions affiliated with an individual’s living and working environment that can make the individual more susceptible to poor health status or vulnerable to disease, in some instances more so than genetics.8,9

Neighborhoods can help foster conditions that either reinforce or hinder the promotion of health, apart from individual lifestyle factors. Residing in a marginalized community can increase an individual’s exposure to physical and psychological stressors that may have a debilitating impact on personal health. Neighborhoods with high levels of poverty may increase the likelihood of exposure to harmful environmental factors, such as poor air quality and toxins in homes. In addition, residents of such neighborhoods may be more disposed to pervasive advertising of unhealthy substances; have more limited options for acquiring healthy food; lack public transportation and spaces for physical activity and leisure; and experience more restricted opportunities for education and employment.10-13

There has been growing interest in the relationship between neighborhood characteristics and well-being. Researches are therefore continuing to take a more in-depth look into such characteristics and how they vary across areas. The increasing focus on this topic stems largely from the growing recognition of the significance of social determinants of health.14-16

The most comprehensive studies of their kind, The Neighborhood Atlas and County Health Rankings, have examined social determinants of health on a neighborhood level throughout the United States.17,18 By ranking neighborhoods based on a number of carefully selected measures, these studies have enabled researchers to measure disparities across regions; examine spatial concentrations of poverty; identify some of the most vulnerable communities; and gain a better understanding of the characteristics that define such communities.17-21 CHART’s analysis seeks to create a New Jersey-specific neighborhood ranking system based on a methodology similar to these studies, but with the addition of other unique measurements.

Vulnerable Populations

In December 2010, the U.S. Department of Health and Human Services launched the Healthy People 2020 initiative with four very focused goals:

  • attain high-quality, longer lives free of preventable disease, disability, injury, and premature death;
  • 28 percent of households receive food support through SNAP benefits
  • achieve health equity, eliminate disparities, and improve the health of all groups;
  • create social and physical environments that promote good health for all; and
  • promote quality of life, healthy development, and healthy behaviors across all life stages.22

The term “population health,” which is defined as the health outcomes of a group of individuals, is designed to evaluate the general health status and disparity of outcomes of a given population. Health status can vary based on a number of variables.23 Despite efforts by policy makers, care providers and individuals themselves, health status can vary significantly due to the presence of physical, emotional, environmental, socio-economic and geographic factors.

This study is designed to identify New Jersey’s most vulnerable communities from a health status perspective and gain insight into the profile of residents living in those communities. Vulnerable populations, as defined in this study, are those at risk of poor physical and psychological health, as well as poor social and economic status.

Key characteristics of vulnerable populations include:

  • POVERTY – individuals with low income often lack access to healthcare services, or live in communities that are compromised by environmental factors;
  • AGE – the elderly and youth populations are more prone to poor health status;
  • RACE AND ETHNICITY – minority populations and residents with low income are correlated to poverty and limited access to healthcare services;
  • OTHER VARIABLES – a host of additional variables – including limited English proficiency/linguistic isolation, undocumented status, homelessness, low education levels, disabilities and lack of medical insurance – are associated with poor health status vulnerability.24,25

Despite efforts to eliminate disparities in health status, specific geographic regions in the state are more vulnerable to the presence of health status risk factors than others. To a great extent, individuals’ current and future health status can be influenced by whether they belong to one or more vulnerable populations. Health status can also be linked to geography, since people at risk for poor health status tend to reside in the most disadvantaged parts of the state.

Understanding where health status vulnerability is most acute and identifying the underlying sources of this vulnerability is a critical step toward improving overall health status. Addressing the risk factors associated with vulnerable communities through targeted quality improvement programs and efforts to mitigate social imbalance can serve to bridge health status gaps that exist in the state. Analytically, linking medical claims to social determinants data could kindle actionable change throughout the healthcare ecosystem.

  1. United States by Density 2019. (n.d.). Retrieved from
  2. Social Determinants of Health. (n.d.). Retrieved from
  3. Social Determinants of Health. (n.d.). Retrieved from
  4. Social Determinants of Health and Vulnerable Populations in Rural Maryland (n.d.). Retrieved from social determinants white paper Dec 2016.pdf.
  5. Emerging Strategies to Ensure Access to Health Care: Addressing the Social Determinants of Health. (n.d.). Retrieved from
  6. Sharma, M., Pinto, A. D., & Kumagai, A. K. (2018). Teaching the Social Determinants of Health. Academic Medicine, 93(1), 25-30. Retrieved from
  7. Health Care’s Blind Side: The Overlooked Connection between Social Needs and Good Health. (2011). Retrieved from
  8. Ritchie, D. (2013). Our Zip Code May Be More Important Than Our Genetic Code: Social Determinants of Health, Law and Policy. Retrieved from
  9. Making the Case for Linking Community Development and Health. (n.d.). Retrieved from
  10. Social Determinants of Health: Thoughts on Neighborhood and Built Environment. (2017). Retrieved from
  11. Neighborhoods and Health Issue Brief 9-24-08. (2008). Retrieved from
  12. Why Place Matters - PolicyLink. (n.d.). Retrieved from
  13. Allen County, IN Vulnerable Populations Study - (n.d.). Retrieved from
  14. 2019 New Jersey Report. (n.d.). Retrieved from
  15. 2019 County Health Rankings Key Findings Report. (n.d.). Retrieved from
  16. How Healthy is your County?: County Health Rankings. (n.d.). Retrieved from
  17. Neighborhood Atlas. (n.d.). Retrieved from
  18. Reports. (n.d.). Retrieved from
  19. Remington, P. L., Catlin, B. B., & Gennuso, K. P. (2015). The County Health Rankings: Rationale and methods. Population Health Metrics, 13(1). Retrieved from
  20. Kind, A. J., & Buckingham, W. R. (2018). Making Neighborhood-Disadvantage Metrics Accessible — The Neighborhood Atlas. New England Journal of Medicine, 378(26), 2456-2458. Retrieved from
  21. About Healthy People. (n.d.). Retrieved from
  22. Population Health. (n.d.). Retrieved from
  23. Populations and Vulnerabilities. (n.d.). Retrieved from
  24. Populations and Vulnerabilities. (n.d.). Retrieved from