Since some measures are based on small samples, won’t there be great fluctuation from year to year making an annual ranking unreliable?

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.