Annually since 2010, the University of Wisconsin Population Health Institute and the Robert Wood Johnson Foundation have produced the County Health Rankings, a “population health checkup” for the nation’s over 3,000 counties (www.countyhealthrankings.org). The health of each county is ranked within each state – from the healthiest to the least healthy – using a model that summarizes the overall health outcomes of each county, as well as the factors that contribute to health [1]. The primary goal of the Rankings is to mobilize action toward community health by stimulating interest among the media and policymakers. The Rankings, in their current form, are an extension of the 2003 to 2008 annual Wisconsin County Health Rankings to the entire United States. In this paper, we review the background and rationale for the expanded Rankings, explain in detail the methods we use to create the health rankings in each state, and discuss the strengths and limitations associated with ranking the health of communities.
Why do we rank?
Ranking is an effective, yet sometimes controversial approach to call attention to differences in a wide variety of areas in society—from the oft-cited US News and World Report rankings to international rankings of economy, education, or technology. Rankings, in general, are desirable because they have the ability to summarize complex information about a topic in a manner that is interpretable to everyone. Oliver suggests that population health rankings can be used to help set agendas — stimulating awareness, motivation, and debate over means to improved health outcomes, and to help establish broad responsibility for population health and the need for multisectorial collaboration to improve outcomes [2]. On the other hand, rankings are often criticized for a variety of reasons, including the arbitrariness of the measures used, inappropriate emphasis of insignificant differences, and the tendency of institutions to focus only on the elements included in the ranks [3,4]. Despite different views about the benefits of rankings, the public and media seems to have an insatiable appetite for them.
Population health rankings, such as the America’s Health Rankings and the County Health Rankings, are often used as a catalyst for the improvement of health by drawing attention to the areas that need improvement through an easily interpretable synthesis of objectively measured community health data [5]. Once the media and community leaders are made aware of problem areas, communities can be engaged to enact evidence-informed health policies and programs to improve health outcomes. Fundamentally, these health rankings are a tool to communicate with health professionals, local community leaders, and the general public, so that they make informed decisions about the health of their communities.
Population health ranking history
The practice of population health ranking likely began as soon as health statistics began to be collected, compiled, and reported publicly. Since the 1960s, the CDC’s Morbidity and Mortality Weekly Report (MMWR) has reported health statistics for the leading causes of death and disability, often by geographic regions like states and metropolitan areas [6]. For example, in 1987, an MMWR publication ranked the rates of health risk behaviors by state, showing that the prevalence of overweight and smoking varied almost two-fold and alcohol-related behaviors varied up to six-fold by state [7]. This report led to a front-page story in the Atlanta Journal-Constitution that showed state ranks for each risk factor [8] followed by media interviews from around the nation. In 1988, one of the authors (PLR) published an article in the MMWR that ranked state-specific death rates due to ischemic heart disease [9], leading to an Associate Press headline that stated, “Midwest, Northeast city life hard on hearts” [10]. This report and the subsequent media attention led to calls to the CDC from health officials and legislators from the states with the highest death rates, insisting that the CDC refrain from publishing rankings in the MMWR.
In 1990, Northwestern National Life Insurance Company sponsored the publication of a report that summarized the health of the 50 states in the US and ranked them from healthiest to least healthy. These reports were unique as they measured the overall health of an entire state. The reports garnered attention in the media, leading to discussions about why health varied dramatically from one state to another [5]. Following this positive experience, Arundel Street Consulting recruited and conducted a Delphi panel that developed a method to compare the healthiness of the general population of each state with other states [11]. This report has been published annually since 1990, now produced by the United Health Foundation as “America’s Health Rankings”.
County Health Rankings history
Based on the media interest from health rankings published in the MMWR and with the state health rankings, county health rankings were first proposed in 1994 by one of the authors (PLR), when he was a Chief Medical Officer at the Wisconsin Division of Public Health. However, efforts to produce these rankings through the state health department were not successful, due in part to concerns about potential backlash from local and statewide policy makers. A comment by a reviewer of an unsuccessful grant proposal submitted to the CDC stated that the release of the rankings “may be quite counterproductive. These often incite great resistance”.
In 2002, the Population Health Institute was established at the University of Wisconsin, with the mission of translating research into policy and practice. One of the first efforts of the Institute was to develop county health rankings for Wisconsin using a model similar to the model used to rank the health of states [12]. Our first report was released that year at a conference of Wisconsin local public health officials and included a press release for the local media. Although the use of ranks was considered, the report instead used a modification of the Consumer Reports-style circles to characterize quartiles from healthiest (Q1) to least healthy (Q4) [13]. This method was found to be difficult to interpret with little interest shown by the local media in reporting the results. Because of this experience, the report was revised and the quartiles were replaced with standard ranking from healthiest (#1) to least healthy (#72). Although this report used the same data as the earlier report, the use of ranking resulted in significant interest among the media and, as a result, more engagement of local health officials [14]. This report became the first in an annual series of “Wisconsin County Health Rankings” published annually thereafter through 2008.
We conducted an evaluation following the release of the 2006 Wisconsin County Health Rankings by searching newspaper, television, and radio coverage and by surveying local public health officials throughout the state [15]. More than 15 newspapers across the state covered the Rankings with headlines such as “Dane County’s residents among state’s healthiest;” “Rock County up, slightly, in health rankings;” “Florence County the healthiest in the state;” and “Washington county ranks 7th healthiest county in state.” Newspaper articles often focused on specific strengths and weaknesses of their local area, such as: “Wealthy and healthy: Waukesha County fares well in new survey;” “Report: County fitter but smoking, drinking too much;” and “County’s health stats in decline: Poor air, smoking, lack of diplomas cause concern”. Nearly all (94%) of the 52 county health officers and regional epidemiologists who responded to our survey reported using the Wisconsin County Health Rankings in their work, primarily for educating policymakers and community partners, performing needs assessments, and identifying program targets.
During the six years that we produced the Wisconsin County Health Rankings, we were contacted by public health institutes in other states interested in using our model to rank counties in their state. Reports published in Tennessee, Kansas, and New Mexico received similar attention among policymakers and the media in each state [16,17]. Following a presentation about the Wisconsin County Health Rankings at a national public health conference [18], we began discussions with the Robert Wood Johnson Foundation about using our methods to rank every county in every state in the nation. In late 2008, the University of Wisconsin Population Health Institute received a grant from the Robert Wood Johnson Foundation to use the model and experience from the Wisconsin County Health Rankings to develop reports for counties in each of the 50 states. This project, entitled “Mobilizing Action Toward Community Health”, supported the development of the current Rankings for all 50 states.
In 2009, we convened a panel of national experts on population health and commissioned a series of publications examining population health metrics and incentives and partnerships for improvement [19-21]. Specifically, these publications examined measures in the five domains used in the Wisconsin County Health Rankings: health outcomes [22], health behaviors [23], health care [24], socioeconomic status [25], and environmental health [26]. Based on these reviews, we sought existing national data sources to determine availability and cost of data at the county level for each of the nation’s more than 3,000 counties.