County Health Rankings: Five Key Elements of The Picture of Health

Mar 28, 2014, 10:16 AM, Posted by Susan Dentzer

Behind the County Health Rankings: What makes a county healthy or unhealthy?
Skip Rope

Paint a portrait of a healthy county, and you’d show the features that contribute to good health: high incomes and levels of education; access to health care; plentiful healthy food, and ample places to exercise.   

Paint a portrait of an unhealthy county, and the palette becomes darker: higher rates of joblessness; more children in poverty; high rates of smoking, obesity and physical inactivity; and more people living in sub-par housing that they may struggle to afford. 

Those, in fact, are the real portraits emerging from the 2014 County Health Rankings, newly released by the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute.

In the five years since the launch of the Rankings, some indicators have improved; such as rates of adult smoking and births to teenagers. But others, such as child poverty, have worsened. Meanwhile, “There’s been an incredible change in the conversation and in local action based on the Rankings,” says Julie Willems Van Dijk, deputy director of the County Health Rankings & Roadmaps. “More and more, we’re seeing people understand that these important factors are determinants of health.” 

The County Health Rankings are based on more than 30 different measures, including key health outcomes such as premature death, or years of life lost before age 75. The conditions influencing health, called “health factors,” include seven newly added this year, such as housing, transportation, the food environment and access to mental health providers.

Spread across more than 3,000 counties in 50 states, that adds up to a lot of data. But in fact, five key measures appear to make the most difference in gauging the health status of any particular county:

  1. The ratio of children in poverty. In one out of 10 U.S. counties, 37 percent or more of children live in households below the federal poverty level. That’s especially true in the South and Southeast, although parts of the West Coast, Northwest and Plains States are also affected. 
  2. College attendance is another key health indicator, as education is closely correlated with health status.  In about one in 10 U.S. counties, the share of adults who have attended college for at least some amount of time is 40 percent or less. Again, that’s especially true in the South. 
  3. Smoking rates are a key driver of poor health. In 10 percent of U.S. counties, 29 percent or more adults are still smoking. The biggest concentration of adult smoking is in the middle South, in states like Kentucky and Tennessee. 
  4. Physical inactivity in its own right predisposes people to poor health, and also contributes to rising rates of obesity. In one in 10 U.S. counties, 35 percent or more of adults are physically inactive–with the worst in the South and Plains states. 
  5. Preventable hospital stays are a key measure that gauges whether someone is hospitalized for conditions that would normally be addressed in an outpatient setting, such as hypertension, short-term diabetes complications, or urinary tract infections. Although this measure focuses on Medicare patients, it’s a good proxy for overall access to high quality health care in a community. High rates of preventable hospitalization can suggest that a county doesn’t have a robust infrastructure of primary care providers, that quality of care is lacking, or that residents don’t have health insurance or other means to pay for care.

Ten percent of U.S. counties have 112 preventable hospital stays for every 1,000 enrollees on Medicare–more than double the rate of best performing counties. The highest rates are in places like Kentucky and West Virginia, as well as other parts of the Eastern U.S. 

Working for change:  Although the portraits of poor county health are stark, hundreds of communities nationwide are working to transform the picture. Consider Santa Cruz County, Calif., one of the winners of the first RWJF Culture of Health Prize (formerly the “Roadmaps to Health” Prize) in 2013, which honors outstanding community partnerships helping people live healthier lives. 

Santa Cruz is typical of many U.S. counties in that health factors aren’t consistent countywide; certain neighborhoods and census tracts are much better off than others. The county seat, the city of Santa Cruz, is home to the local branch of the state university and features high housing values and a well-educated population. The southern end of the county, with towns like Watsonville, boasts fields of fruits and vegetables and thousands of low-income agricultural workers.   

Santa Cruz has been collecting and analyzing local health data for nearly two decades through the Community Assessment Project, under the auspices of United Way of Santa Cruz County. Drawing on the project’s findings, as well as those of the County Health Rankings, community leaders have targeted priorities for action.   

One result has been the creation of Jóvenes SANOS, a local youth advocacy project, which works to improve access to healthy food choices and physical activity—for example, by helping to bring healthy vending machine options to the county’s Metro stations. And even before the Affordable Care Act took full effect, a collaborative effort among health care providers, insurers and county officials worked to ensure that the county’s uninsured children had access to health care. 

The County Health Rankings website is a gold mine of information for communities that want to embark on similar journeys to better health. Check out the County Health Rankings & Roadmaps Action Center, which contains guides advising different community stakeholders about how they can get involved, as well as specific activities for building a culture of health. Also on the website is What Works for Health, where summaries of the research evidence can guide community decision-making about policies and programs that genuinely improve health. 

And watch the Foundation’s First Friday Google+ Hangout on April 4 from 12 p.m. to 1 p.m. ET to learn how business, government, public health, education and other sectors have derived key lessons from the County Health Rankings and are taking meaningful action to improve health.

RSVP to join us and watch the live broadcast Friday, April 4, at 12 p.m. ET, directly on this page.

We're taking questions from viewers on Twitter at @RWJF and on this event page. Just tag your questions with #RWJF1stFri  and we'll do our best to answer them during the hour.