Frequently Asked Questions

To serve as a call to action for communities to

• Understand the health problems in their community
• Get more people involved in improving the health of communities
• Recognize that factors outside medical care influence health

Ranking the health of counties using not only traditional health outcomes, but also the broad range of health factors, can mobilize action on the part of governmental public health and in many other sectors that can influence and are affected by health.

• Raising awareness in the general community about the multiple factors that influence health via media interviews and follow-up conversations.
• Initiating community health assessment and planning efforts where none previously existed
• Celebrating successes and promoting existing community health improvement efforts
• Informing policy makers, particularly Local Boards of Health, about the many factors that affect a community's health and about community health improvement planning
• Revitalizing or refining existing community health assessment and improvement plans
• Citing the County Health Rankings as justification in securing grant funding to conduct community health improvement efforts and/or to address the determinants of health
• Providing feedback to the University of Wisconsin Population Health Institute to improve the Rankings methodology and report.

We believe that there are two separate sets of messages to convey. One set addresses how healthy a county currently is and the other addresses how healthy a county might be in the future based on the many factors that influence health. However, if a single ranking of the “healthiest” counties is desired, we use the health outcomes rank.

America’s Health Rankings already ranks the health of states -- we have tried to align our measures as closely as possible with these Rankings.

The purpose of the County Health Rankings is to compare counties within states. We discourage comparisons between states for several reasons:

• The County Health Rankings is not intended to be a national report that finds the 10 or 15 least healthy counties in the nation and focuses only on that. The Rankings are intended to provide a tool for each state to identify counties where health disparities exist.
• Our effort is to focus on state-specific county rankings, and we won't actually provide any county rankings across state boundaries.
• Some of the measures that we use are state-specific and make comparisons across state boundaries difficult.
• There are existing resources that can be used to compare counties across the nation. One is the Community Health Status Indicators (CHSI) Database which the Human Resource Services Administration (HRSA) put together. The CHSI database is periodically updated and provides a valuable resource for counties that are interested in comparing themselves to peer counties with similar demographics.

There is not one formula for where communities should put their efforts. Because the County Health Rankings are based on broad measures and include multiple years of data, it is important for communities to look at further information prior to making a decision about next steps. Using a formal assessment process, such as Mobilizing for Action through Planning and Partnerships (MAPP), can assist in these efforts. A more extensive drill down into local data and an opportunity to hear from community members about what matters most to them are important next steps.

We encourage states and communities to use the Rankings tool as a compelling case to educate your communities that the health system is really everyone in the community. Health is everybody's business, and we can't improve health in communities by simply looking at more health care or more services delivered by governmental public health.

The County Health Rankings are designed as a call to action – the use of ranks can often serve as a more effective tool for drawing attention to community health issues than lengthy listings of indicators. We encourage any community that has not already done so to use the Rankings as a stimulus to engage community members in a more detailed community health assessment, using whatever additional data sources they have available. The Rankings can be used as a pointer to suggest areas where more in-depth analysis might be helpful.

We are happy to provide copies of both of these graphics for your use: County Health Rankings model and our Take Action graphic. If you use these images in a publication, please use the following citation:

University of Wisconsin Population Health Institute. County Health Rankings 2011. Accessible at www.countyhealthrankings.org.

Prison inmates are included in county-level counts for the following ranked measures:

• Premature death
• Motor vehicle crash deaths
• Homicide
• Low birthweigh births
• Teen births

No, many of the measures were calculated for the County Health Rankings by other organizations. For example, measures from the National Vital Statistics System and the Behavioral Risk Factor Surveillance System were calculated by staff at the National Center for Health Statistics/Centers for Disease Control and Prevention. Similarly, the health care quality measures were calculated for us by the Dartmouth Institute.

The most frequent reason why numbers of the Rankings web site may not match other numbers that states have will be due to different definitions of measures, different time periods, or different samples or denominators. Communities should rely on their own state's data for their own more detailed community health assessments.

This is a challenge. We have worked on criteria for managing small numbers but, in spite of this, counties with smaller populations may see substantial variation in some measures from year to year (and consequently in some of their ranks). We encourage these communities to view the Rankings as a tool to raise awareness annually of the many factors that affect health. As noted elsewhere, the Rankings are not the best tool for measuring progress from year to year. We encourage communities to develop a specific evaluation plan as part of comprehensive community health improvement planning.

Each year's data are weighted equally.

Some counties in the nation are too small to have reliable measurements for health outcome measures. Those counties are not ranked. If a county has data for enough measures to be ranked but is missing data for any individual measure, we assign the county the same value as the state mean for that measure. To overcome unstable and unreliable estimates due to small numbers, such as with the measures from the  Behavioral Risk Factor Surveillance System (BRFSS), is to combine multiple years of data. This means that although the Rankings are useful for differentiating between places that are and are not healthy, they are not a good tool for setting objectives and tracking progress from year to year. 

The major goal of the Rankings is to raise awareness about the many factors that influence health and that health varies from place to place. We encourage communities to focus on the strengths and challenges within their own community and use the Rankings as a call to action. The Rankings are based on summary measures of the indicators, using z-scores (not ranks) to standardize each measure to the same scale. We do not suggest that the ranks themselves represent statistically significant differences from county to county. We do not rank the individual measures. To de-emphasize the differences between individual county ranks, we provide quartile maps for the summary ranks and specific measures for each state. These maps can be used to draw attention to areas of a state with better or worse health, rather than specific discussions of small differences in rank. For those users who wish drill down within the Rankings and determine whether a county's performance on a specific measure is significantly different from that of another county or the state's mean, we provide confidence intervals for most measures, where applicable.

In part, the County Health Rankings aim to show that where you live matters to your health and that disparities exist within every state. But disparities exist within most counties as well. We encourage communities to use the Rankings as a starting point to delve more deeply into data that may highlight disparities within counties. Communities can do this by initiating a community health assessment or using the Rankings to draw attention to thorough assessments that have already been done. We have provided information in our Data Guide for communities that need help getting started.

The County Health Rankings are not necessarily the best way to track improvement over time because they are based on broad measures and, in order to be valid for counties of all sizes, many of the measures are based on multiple years of data. We encourage counties to use their own local data sources to identify ways to measure progress from year to year.

At best, rankings are only one indicator of a community’s health.  We provide the rationale for the decisions we’ve made about which measures and weights we use in our model. The main purpose of the Rankings is to serve as a tool to raise awareness about the many factors that influence health and an opportunity to engage more people in the discussion. They are also a tool to highlight that health varies from place to place. We strongly encourage communities to take a further look at local data and have further discussion about the meaning of these data to determine a plan of action for their community.

Each county's ranks are calculated within a specific state so you cannot compare your county's ranks with those for a county in a different state. However, you can compare the values for the Health Outcomes measures from one state to another.  We advise caution in comparing the Health Factors measures across states because our measures for Health Factors are only uniform within states not across states. Users should refer to our guidelines for comparing measures across states to find the differences that occur for some measures (such as high school graduation rates and violent crime).  Although the County Health Rankings data tool does not include an online feature for comparing counties in different states, users can print out the “snapshots” for adjoining counties in different states to look for similarities and differences in the measures across the counties.

Physical environment is an important determinant but it is difficult to find good measures at a county level. We were hoping to be able to add a county-level measure of water quality but were not able to acquire reliable data on this community characteristic. We have added a new measure this year, Access to Recreational Facilities, to draw attention to the need for opportunities for exercise within communities. Ideally, we would have measures of safe sidewalks, parks, bicycle trails, etc to reflect this important need but there are no nationwide sources that we are aware of where county-level data are available on these characteristics.

The only quality of care measures that were available at a county level throughout the nation were from our only nationalized system of care—Medicare. We acknowledge it would be better to have a broader set of quality of care measures, but they are not currently available nation-wide for other populations.

We use a single measure of premature death for its simplicity - we believe that the focus on premature death, giving greater weight to loss of early life in the early years, the preventability of many of these deaths is an important message.  Measures of cause-specific death are less reliable than overall death rates, particularly for smaller counties. However, as a follow up to the Rankings, we encourage more detailed assessments of the causes of premature death in a community.

We acknowledged that there are other important measures of health that we do not include, e.g. blood pressure, salt intake, child obesity, teen smoking, teen alcohol use.  Including such measures would be helpful but unfortunately, county-level data on these risk factors are not consistently available in enough states for us to incorporate such measures at this time.

Timely and appropriate prenatal care is important. However, since states are at different stages of implementation with revisions to birth certificates, we were advised not to use a measure of prenatal care in the County Health Rankings.