Ji E Chang
Ji E Chang
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Associate Professor of Public Health Policy and Management
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Professional overview
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Ji Eun Chang, Ph.D., is an Associate Professor in the Department of Public Health Policy and Management at the New York University School of Global Public Health, where she also serves as the public health policy and management concentration director for the Ph.D. program. Professor Chang uses mixed-methods research designs and draws from qualitative, quantitative, and geospatial data to demonstrate disparities and highlight barriers faced by safety net providers and underserved patients in accessing equitable care.
Professor Chang is the principal investigator of the AI4Healthy Cities Initiative in New York City, a multi-city collaboration between the Novartis Foundation, Microsoft AI4Health, and local health officials to reduce cardiovascular health inequities through big data analytics. Dr. Chang is also the co-principal investigator of an NIH NIDA-funded study to support implementing transitional opioid programs in safety net hospitals. Dr. Chang received a B.A. in Economics from the University of California at Berkeley, an M.S. in Public Policy and Management from Carnegie Mellon University, and a Ph.D. in Public Administration from New York University in 2016. -
Education
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BA, Economics, University of California at Berkeley, Berkeley, CAMS, Public Policy and Management, Carnegie Mellon University, Pittsburgh, PAPhD, Public Administration, New York University, New York, NY
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Honors and awards
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Governor’s Scholar (2007)Regents and Chancellors’ Scholar (2005)
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Areas of research and study
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Cardiovascular DiseaseHealth DisparitiesHealth EquityPublic Health ManagementPublic Health ManagementSafety Net Providers and PatientsSubstance Use Disorders
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Publications
Publications
Initiatives to Support the Transition of Patients With Substance Use Disorders From Acute Care to Community-based Services Among a National Sample of Nonprofit Hospitals
AbstractChang, J. E., Krawczyk, N., Rivera, B. D., Chang, J. E., Lindenfeld, Z., & Franz, B. (n.d.).Publication year
9900Journal title
Journal of Addiction MedicineAbstract~A Year After Implementation of the Telehealth Waiver: Being Offered and Utilizing Video-Specific Telehealth Among Dual-Eligible Medicare Recipients During the COVID-19 Pandemic
AbstractChang, J. E., Choi, J., Kim, G., Choi, S., & Chang, J. E. E. (n.d.).Publication year
2025Journal title
Journal of public health management and practice : JPHMPVolume
30Issue
2Page(s)
255-266AbstractTelehealth is an essential tool to provide access to care while reducing infection exposure for high-risk populations during the COVID-19 pandemic. Our study aims to examine factors associated with telehealth availability and usage among Medicare and dual-eligible recipients 1 year after implementation of the Medicare's temporary telehealth waiver.Association of Hospital Decision-making and Adoption of Health-Related Social Needs Programs Among US Hospitals
AbstractChang, J. E., Zein, D., Cronin, C., Puro, N., & McNeil, E. (n.d.).Publication year
2025Journal title
JAMA Network OpenAbstract~Examining the Relationship between Local Governmental Expenditures on the Social Determinants of Health and County-Level Overdose Deaths, 2017-2020
AbstractLindenfeld, Z., Mauri, A. I., & Chang, J. E. (n.d.).Publication year
2025Journal title
Journal of Public Health Management and PracticeVolume
31Issue
1Page(s)
20-28AbstractContext Prior studies have examined the social determinants of health (SDOH) characteristics of counties with elevated rates of overdose deaths. However, this research often ignores variation in upstream governmental investment in these SDOH categories. Objective To examine the association of local governmental investments in SDOH with drug overdose mortality at the county level, controlling for demographic and socioeconomic characteristics. Design Longitudinal analysis from 2017 to 2020. Setting United States counties. Participants 3126 counties. Main Outcome and Measures The primary study outcome was county overdose death rates per 100 000 population taken from the Centers for Disease Control and Prevention. The main predictor of interest was the per capita average of local governmental expenditures in public health, social service, and education drawn from the US Census of Governments, categorized into quartiles. Covariates included county-level socioeconomic and demographic characteristics as well as county-level SUD services from the AHRQ SDOH Database. Results In longitudinal multivariate linear regression models with state and year fixed effects, counties in the highest 3 quartiles of SDOH spending had significantly lower rates of overdose deaths compared with counties in the lowest quartile of SDOH spending; in particular, counties in quartile 2 had an average of 9.09 fewer overdose deaths per 100 000 population (95% CI: -12.58, -5.60), counties in quartile 3 had an average of 13.18 fewer deaths per 100 000 population (95% CI: -17.56; -8.80), and counties in quartile 4 had an average of 13.92 deaths per 100 000 population (95% CI: -19.16, -8.68). Conclusions Our findings demonstrate that higher levels of local governmental investments in SDOH were associated with significantly lower rates of overdose death in US counties after controlling for socioeconomic and demographic characteristics. Going forward, research should focus on determining causality in this relationship, the mechanisms through which this relationship occurs, as well as assess the impact of local public health expenditures allocated toward SUD prevention and treatment specifically on substance use outcomes at the local level.Examining the Relationship Between Local Governmental Expenditures on the Social Determinants of Health and County-Level Overdose Deaths, 2017-2020
AbstractChang, J. E., Lindenfeld, Z., Mauri, A. I., & Chang, J. E. (n.d.).Publication year
2025Journal title
Journal of public health management and practice : JPHMPVolume
31Issue
1Page(s)
20-28AbstractPrior studies have examined the social determinants of health (SDOH) characteristics of counties with elevated rates of overdose deaths. However, this research often ignores variation in upstream governmental investment in these SDOH categories.Forging hospital and community partnerships to enable care coordination for opioid use disorder
AbstractLindenfeld, Z., Franz, B., Lai, A., Pagán, J. A., Fenstemaker, C., Cronin, C. E., & Chang, J. E. (n.d.).Publication year
2025Journal title
Addiction Science and Clinical PracticeVolume
20Issue
1AbstractBackground: Programs that aim to increase access to substance use disorder (SUD) treatment in hospital-based settings have proliferated in recent years. These efforts include transitional opioid programs (TOPs), which navigate patients to community-based SUD treatment programs post-discharge. Successful navigation from TOPs to outpatient treatment hinges on effective coordination between hospitals and post-discharge endpoints, yet it is unclear how hospitals can best develop effective partnerships with outpatient treatment organizations. The objective of this study is to synthesize the common themes underpinning the development of partnerships to facilitate care transitions between TOPs and ongoing SUD treatment. Methods: Qualitative study with staff and providers from hospitals affiliated with four safety-net health systems (n = 21) and leaders from community-based organizations (CBOs) and treatment facilities that had established referral partnerships with one of the four health systems in our study (n = 4). Results: Analysis of interview transcripts revealed seven common themes that underpinned the development of care transitions partnerships: (1) Active, intentional outreach; (2) Responding to a community need; (3) External Enabling Factors; (4) Leveraging reputations and community connections; (5) Focusing on operations; (6) Reciprocal relationships; and (7) Building Infrastructure and Processes to Ensure Collaboration. The seven identified themes were categorized into three groups corresponding to different partnership development stages. The first group revolves around the initial stage of meeting and developing a relationship (themes #1–4). The second set focuses on navigating and resolving challenges that arise in the partnership (themes #5–6). Lastly, the third group pertains to sustaining a partnership long-term (theme #7). Conclusions: This study identifies seven core themes underlying the development of care transition partnerships for SUD patients within four safety net health systems and their CBO partners. These themes demonstrate how partner organizations can establish the trust, reciprocity, and commitment necessary to support patients through the critical transition period.Forging Hospital and Community Partnerships to Enable Care Coordination for Opioid Use Disorder
AbstractLindenfeld, Z., Lai, A., Pagan, J., Cronin, C., Franz, B., & Chang, J. E. (n.d.).Publication year
2025Journal title
Addiction Science & Clinical PracticeAbstract~Implementation Strategies to Enhance Safety-Net Hospitals’ Adoption of Screening, Brief Intervention, and Referral to Treatment for Opioid Use Disorder
AbstractLindenfeld, Z., Franz, B., Fenstemaker, C., Lai, A., Pagan, J. A., Cronin, C. E., & Chang, J. E. (n.d.).Publication year
2025Journal title
Journal of general internal medicineAbstractBackground: To support adoption of Screening, Brief Intervention, and Referral to Treatment (SBIRT) for opioid use disorder (OUD), hospitals are likely to benefit from implementation strategies that are responsive to their unique environments. Yet there remains a gap in knowledge regarding which implementation strategies are needed to support SBIRT implementation and sustainment for OUD within safety-net hospitals. Objectives: To obtain expert consensus on the most effective implementation strategies to enhance the adoption of SBIRT for OUD in safety-net hospitals. Design and Setting: A modified Delphi study, with two rounds of online surveys. Participants: Eighteen US-based experts from within the fields of OUD-focused health services research, addiction medicine, and emergency medicine. Main Measures: The primary outcome was consensus on 35 potential SBIRT implementation strategies, ranked on a 5-point Likert scale across three domains: Effectiveness, Feasibility, Impact on Equity. Consensus across respondents within both rounds was evaluated using the interquartile range. If the IQR was 1 or below on the 0 to 5 Likert scale, consensus was considered obtained. Items with a median value of 4 or higher were considered high priority. Results: Following two rounds of ranking, consensus was achieved for all survey items. In total, 62.85% strategies (n = 22) were rated as High in Effectiveness, 20.0% (n = 7) were rated as High in Feasibility, and 11.42% (n = 4) were rated High in Impact on Equity. Seven strategies ranked high in two areas, with three—Identify and Prepare Champions, Identify Early Adopters, and Conduct Educational Meetings—ranked as highly effective and feasible. Conclusions: This consensus process provides strong support for implementation strategies that can be used to guide future practice and study. This work can encourage implementation of SBIRT for OUD within safety-net hospitals, and set the stage for future studies to evaluate the impact of different implementation strategies on patient outcomes following SBIRT.Initiatives to Support the Transition of Patients With Substance Use Disorders From Acute Care to Community-based Services Among a National Sample of Nonprofit Hospitals
AbstractChang, J. E., Krawczyk, N., Rivera, B. D., Chang, J. E., Lindenfeld, Z., & Franz, B. (n.d.).Publication year
2025Journal title
Journal of addiction medicineVolume
18Issue
2Page(s)
115-121AbstractHospitals are a key touchpoint to reach patients with substance use disorders (SUDs) and link them with ongoing community-based services. Although there are many acute care interventions to initiate SUD treatment in hospital settings, less is known about what services are offered to transition patients to ongoing care after discharge. In this study, we explore what SUD care transition strategies are offered across nonprofit US hospitals.Inpatient Psychiatric Unit Availability Within US Short-Term Acute Care Hospitals, 2011-2023
AbstractLindenfeld, Z., Chang, J. E., Cantor, J., McCollough, C., & McBain, R. (n.d.).Publication year
2025Journal title
JAMA Network OpenAbstract~Patient-Provider Communication for Lonely, Socially Isolated Adults in Medicare
AbstractChang, J. E., Park, S., Nguyen, A. M., Lindenfeld, Z., & Chang, J. E. E. (n.d.).Publication year
2025Journal title
American journal of preventive medicineAbstractOlder adults experiencing loneliness or social isolation may experience poor patient-provider communication, potentially contributing to suboptimal healthcare utilization, particularly in mental healthcare. However, empirical evidence is limited. Thus, this study examined whether there were differences in patient-provider communication and healthcare utilization between Medicare beneficiaries with and without loneliness and social isolation.Patient–Provider Communication for Lonely, Socially Isolated Adults in Medicare
AbstractPark, S., Nguyen, A. M., Lindenfeld, Z., & Chang, J. E. (n.d.).Publication year
2025Journal title
American journal of preventive medicineVolume
68Issue
5Page(s)
905-913AbstractIntroduction: Older adults experiencing loneliness or social isolation may experience poor patient–provider communication, potentially contributing to suboptimal healthcare utilization, particularly in mental healthcare. However, empirical evidence is limited. Thus, this study examined whether there were differences in patient–provider communication and healthcare utilization between Medicare beneficiaries with and without loneliness and social isolation. Methods: This study conducted a cross-sectional study using data from the 2021 Medical Expenditure Panel Survey. Outcomes were patient–provider communication and healthcare utilization. The primary independent variables were loneliness and social isolation. Regression analysis was conducted to estimate adjusted differences in outcomes between Medicare beneficiaries with and without loneliness and social isolation. The analysis was conducted in September 2024. Results: The sample included 4,433 Medicare beneficiaries. Medicare beneficiaries experiencing loneliness were 4.0 percentage points (95% CI=1.0, 7.1) more likely to report poor patient–provider communication compared to those without loneliness. Similarly, those with social isolation were 2.0 percentage points (1.1, 2.9) more likely to report poor communication than those without social isolation. The rates of mental healthcare utilization were higher among those with loneliness (1.8 [1.0, 2.6], 1.5 [0.8, 2.2], and 3.1 [1.1, 5.1] for social workers, psychologists, and psychiatrists) or social isolation (2.3 [0.6, 4.0] for psychiatrists), but the overall level of mental healthcare utilization remained relatively low. Conclusions: These findings highlight significant disparities in patient–provider communication among Medicare beneficiaries experiencing loneliness and social isolation. These disparities may partly result from limited engagement with mental health services, which could help address their specific healthcare needs.Trends in the Prioritization and Implementation of Substance Use Programs by Nonprofit Hospitals: 2015-2021
AbstractChang, J. E., Chang, J. E. E., Cronin, C. E., Pagán, J. A., Simon, J., Lindenfeld, Z., & Franz, B. (n.d.).Publication year
2025Journal title
Journal of addiction medicineVolume
17Issue
4Page(s)
e217-e223AbstractHospitalizations are an important opportunity to address substance use through inpatient services, outpatient care, and community partnerships, yet the extent to which nonprofit hospitals prioritize such services across time remains unknown. The objective of this study is to examine trends in nonprofit hospitals' prioritization and implementation of substance use disorder (SUD) programs.A Year After Implementation of the Telehealth Waiver : Being Offered and Utilizing Video-Specific Telehealth Among Dual-Eligible Medicare Recipients During the COVID-19 Pandemic
AbstractChoi, J., Kim, G., Choi, S., & Chang, J. E. (n.d.).Publication year
2024Journal title
Journal of Public Health Management and PracticeVolume
30Issue
2Page(s)
255-266AbstractObjective: Telehealth is an essential tool to provide access to care while reducing infection exposure for high-risk populations during the COVID-19 pandemic. Our study aims to examine factors associated with telehealth availability and usage among Medicare and dual-eligible recipients 1 year after implementation of the Medicare’s temporary telehealth waiver. Design, Setting, and Participant: A cross-sectional, phone survey with a national representative sample of Medicare recipients. We obtained a final study sample from the Winter 2021 COVID-19 Supplement of Medicare Current Beneficiary Survey dataset (N = 10 586). We examined associations for being offered and having had telehealth visits or any video telehealth visits during the pandemic since November 1, 2020. Main Outcome Measures: Our primary outcomes were being offered any telehealth, being offered any video telehealth, having had any telehealth visit, and having had any video telehealth. Results: Although dual eligibility was not significantly associated with being offered or having had any telehealth services during the pandemic, those who were dual eligible were more likely to have had video telehealth visits (adjusted odds ratio = 1.39, 95% confidence interval 1.04-1.86, P = .03) compared with those with non-dual eligibility. Recipients with disability eligibility, technology access, and severe chronic conditions were more likely to have been offered or have had telehealth. At the same time, those who lived in the nonmetropolitan area were less likely to have been offered or have had telehealth, including video telehealth. Conclusions: Our findings suggest that the federal waivers to expand telehealth services were successful in continuing care for vulnerable Medicare recipients. The providers’ specific outreach and intervention efforts to offer telehealth visits are crucial for dual-eligible recipients. To increase video telehealth uptake, technology access and services to rural areas should be prioritized.Association of Telehealth Utilization Among Patients with Heart Disease with Fewer Emergency Department Visits and Hospitalizations during COVID-19 Pandemic
AbstractChang, J. E., Lee, J., Bhatt, A., Jackson, S., Ton, X., Chang, J., Pollack, M., & Luo, F. (n.d.).Publication year
2024Journal title
Health Affairs ScholarIssue
2047-9980 (Electronic)Abstract~Barriers and Facilitators to Establishing Partnerships for Substance Use Disorder Care Transitions Between Safety-Net Hospitals and Community-Based Organizations
AbstractChang, J. E., Lindenfeld, Z., Franz, B., Lai, A. Y. Y., Pagán, J. A., Fenstemaker, C., Cronin, C. E., & Chang, J. E. E. (n.d.).Publication year
2024Journal title
Journal of general internal medicineVolume
39Issue
12Page(s)
2150-2159AbstractThe effectiveness of hospital-based transitional opioid programs (TOPs), which aim to connect patients with substance use disorders (SUD) to ongoing treatment in the community following initiation of medication for opioid use disorder (MOUD) treatment in the hospital, hinges on successful patient transitions. These transitions are enabled by strong partnerships between hospitals and community-based organizations (CBOs). However, no prior study has specifically examined barriers and facilitators to establishing SUD care transition partnerships between hospitals and CBOs.Comparing Rates of Undiagnosed Hypertension and Diabetes in Patients With and Without Substance Use Disorders
AbstractChang, J. E., Lindenfeld, Z., Chen, K., Kapur, S., & Chang, J. E. (n.d.).Publication year
2024Journal title
Journal of general internal medicineVolume
39Issue
9Page(s)
1632-1641AbstractIndividuals with substance use disorders (SUDs) have increased risk for developing chronic conditions, though few studies assess rates of diagnosis of these conditions among patients with SUDs.Comparing Rates of Undiagnosed Hypertension and Diabetes in Patients with and without Substance Use Disorders
AbstractChang, J. E., Lindenfeld, Z., Chen, K., Kapur, S., & Chang, J. (n.d.).Publication year
2024Journal title
Journal of General Internal MedicineAbstract~Discrimination in Medical Settings across Populations: Evidence From the All of Us Research Program
AbstractChang, J. E., Wang, V. H.-C. H., Cuevas, A. G., Osokpo, O. H. H., Chang, J. E. E., Zhang, D., Hu, A., Yun, J., Lee, A., Du, S., Williams, D. R., & Pagán, J. A. (n.d.).Publication year
2024Journal title
American journal of preventive medicineVolume
67Issue
4Page(s)
568-580AbstractDiscrimination in medical settings (DMS) contributes to healthcare disparities in the United States, but few studies have determined the extent of DMS in a large national sample and across different populations. This study estimated the national prevalence of DMS and described demographic and health-related characteristics associated with experiencing DMS in seven different situations.Examining the relationship between social determinants of health, measures of structural racism and county-level overdose deaths from 2017-2020
AbstractChang, J. E., Lindenfeld, Z., Silver, D., Pagán, J. A., Zhang, D. S. S., & Chang, J. E. E. (n.d.).Publication year
2024Journal title
PloS oneVolume
19Issue
5Page(s)
e0304256AbstractDespite being an important determinant of health outcomes, measures of structural racism are lacking in studies examining the relationship between the social determinants of health (SDOH) and overdose deaths. The aim of this study is to examine the association between per capita revenue generated from fines and forfeitures, a novel measure of structural racism, and other SDOH with county-level overdose deaths from 2017-2020.Examining the relationship between social determinants of health, measures of structural racism and county-level overdose deaths from 2017–2020
AbstractLindenfeld, Z., Silver, D. R., Pagán, J. A., Zhang, D. S., & Chang, J. E. (n.d.).Publication year
2024Journal title
PloS oneVolume
19Issue
5 MAYAbstractIntroduction Despite being an important determinant of health outcomes, measures of structural racism are lacking in studies examining the relationship between the social determinants of health (SDOH) and overdose deaths. The aim of this study is to examine the association between per capita revenue generated from fines and forfeitures, a novel measure of structural racism, and other SDOH with county-level overdose deaths from 2017–2020. Methods This longitudinal analysis of 2,846 counties from 2017–2020 used bivariate and multivariate Generalized Estimating Equations models to estimate associations between county overdose mortality rates and SDOH characteristics, including the fines and forfeitures measure. Results In our multivariate model, higher per capita fine and forfeiture revenue (5.76; CI: 4.76, 6.78), households receiving food stamps (1.15; CI: 0.77, 1.53), residents that are veterans (1.07; CI: 0.52, 1.63), substance use treatment availability (4.69; CI: 3.03, 6.33) and lower population density (-0.002; CI: -0.004, -0.001) and percent of Black residents (-0.7‘; CI: -1.01, -0.42) were significantly associated with higher overdose death rates. There was a significant additive interaction between the fines and forfeitures measure (0.10; CI: 0.03, 0.17) and the percent of Black residents. Conclusions Our findings suggest that structural racism, along with other SDOH, is associated with overdose deaths. Future research should focus on connecting individual-level data on fines and forfeitures to overdose deaths and other health outcomes, include measures of justice-related fines, such as court fees, and assess whether interventions aimed at increasing economic vitality in disadvantaged communities impact overdose deaths in a meaningful way.Hospital use of common Z-codes for Medicare fee-for-service beneficiaries, 2017-2021
AbstractChang, J. E., Chang, J. E., Smith, N., Lindenfeld, Z., & Weeks, W. B. (n.d.).Publication year
2024Journal title
Health affairs scholarVolume
2Issue
1Page(s)
qxad086AbstractRecognizing the impact of the social determinants of health (SDOH) on health outcomes, in 2016, the Centers for Medicare and Medicaid Services recommended the use of (ICD-10), Z-codes to capture patients' health-related social needs. We examined changes in Z-code utilization to document health-related social needs for Medicare fee-for-service recipients among US hospitals between 2017 and 2021 across 5 common SDOH domains. We found that, while 56.9% of hospitals had at least 1 Z-code recorded in at least 1 patient per year, apart from those referring to housing needs, rates of Z-code adoption were low. Additionally, hospitals that were general medical, part of a teaching institution, affiliated with larger health systems, and of medium to large size had greater odds of utilizing Z-codes. Findings from this study highlight the need for continued efforts in promoting the consistent use of standardized SDOH capturing methods like Z-code documentation, such as provider training.Identifying and Characterizing Models of Substance Use Treatment in Outpatient Substance Use Treatment Facilities
AbstractChang, J. E., Lindenfeld, Z., Cantor, J. H., & Chang, J. E. (n.d.).Publication year
2024Journal title
Journal of studies on alcohol and drugsAbstractGiven that individuals with substance use disorders (SUDs) have a variety of needs beyond substance use, it is critical to examine the comprehensiveness of services offered within outpatient SUD treatment facilities, where many individuals with SUDs receive care. This study's objective is to develop clusters of services offered, and assess organizational, policy, and environmental characteristics associated with having a more comprehensive treatment model.Initiatives to Support the Transition of Patients With Substance Use Disorders From Acute Care to Community-based Services Among a National Sample of Nonprofit Hospitals
AbstractKrawczyk, N., Rivera, B. D., Chang, J. E., Lindenfeld, Z., & Franz, B. (n.d.).Publication year
2024Journal title
Journal of Addiction MedicineVolume
18Issue
2Page(s)
115-121AbstractBackground Hospitals are a key touchpoint to reach patients with substance use disorders (SUDs) and link them with ongoing community-based services. Although there are many acute care interventions to initiate SUD treatment in hospital settings, less is known about what services are offered to transition patients to ongoing care after discharge. In this study, we explore what SUD care transition strategies are offered across nonprofit US hospitals. Methods We analyzed administrative documents from a national sample of US hospitals that indicated SUD as a top 5 significant community need in their Community Health Needs Assessment reports (2019-2021). Data were coded and categorized based on the nature of described services. We used data on hospitals and characteristics of surrounding counties to identify factors associated with hospitals' endorsement of transition interventions for SUD. Results Of 613 included hospitals, 313 prioritized SUD as a significant community need. Fifty-three of these hospitals (17%) offered acute care interventions to support patients' transition to community-based SUD services. Most (68%) of the 53 hospitals described transition strategies without further detail, 23% described scheduling appointments before discharge, and 11% described discussing treatment options before discharge. No hospital characteristics were associated with offering transition interventions, but such hospitals were more likely to be in the Northeast, in counties with higher median income, and states that expanded Medicaid. Conclusions Despite high need, most US hospitals are not offering interventions to link patients with SUD from acute to community care. Efforts to increase acute care interventions for SUD should identify and implement best practices to support care continuity.Machine learning to evaluate the relationship between social determinants and diabetes prevalence in New York City
AbstractChang, J. E., Tanner, D., Zhang, Y., Chang, J. E. E., Speyer, P., Adamson, E., Aerts, A., Lavista Ferres, J. M., & Weeks, W. B. (n.d.).Publication year
2024Journal title
BMJ public healthVolume
2Issue
2Page(s)
e001394AbstractDiabetes is a leading contributor to cardiovascular disease and mortality; social determinants of health (SDOH) are associated with disparities in diabetes risk. Quantifying the cumulative impact of SDOH and identifying the SDOH most associated with diabetes prevalence at the neighbourhood level can help policy-makers design and target local interventions to mitigate these disparities. Machine learning (ML) methods can provide novel insights and help inform public health intervention strategies in a place-based manner.