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Rural counties have the highest rates of premature death, lagging far behind other counties.


The County Health Rankings & Roadmaps program helps communities identify and implement solutions that make it easier for people to be healthy in their neighborhoods, schools, and workplaces. Ranking the health of nearly every county in the nation, the County Health Rankings illustrate what we know when it comes to what is keeping people healthy or making people sick. The Roadmaps show what we can do to create healthier places to live, learn, work, and play. The Robert Wood Johnson Foundation collaborates with the University of Wisconsin Population Health Institute to bring this program to communities across the nation.

Now in its seventh year, the County Health Rankings continue to bring revealing data to US counties. This report offers key findings from this year’s Rankings release and includes answers to the following questions:

A. How Does Health Vary Across Rural and Urban Counties?
B. How Do Health Gaps Among Counties Differ by State?
C. What Are the New Measures of Each County’s Health?

Summary of Key Findings

  • Rural counties have had the highest rates of premature death for many years, lagging far behind other counties. While urban counties continue to show improvement, premature death rates are worsening in rural counties.
  • Looking solely at state averages for the factors that influence health masks the significant gaps in health that exist between counties within each state.
  • Three new measures are highlighted:
    • Residential segregation of blacks and whites is a fundamental cause of health disparities in the US. Black/white residential segregation is highest in the Northeast and Great Lakes region and lowest along the Southeastern seaboard.
    • The rate of deaths due to drug overdoses has increased 79 percent since 2002. Drug overdose deaths are highest in Northern Appalachia and in parts of the West/ Southwest, and lowest in the Northeast. Compared with other types of counties, rural counties have higher rates of drug overdose deaths.
    • Sleep is an important part of a healthy lifestyle. Insufficient sleep can have serious negative effects on health. On average, about one third of adults report getting insufficient sleep (less than 7 hours a night on average). In some counties, almost one in two residents report insufficient sleep.

How Does Health Vary Across Rural And Urban Counties?

Ranking counties within states often leads to questions about how health outcomes and health factors vary across states. For a closer look at health by county type and size, we separated counties into the following categories:

Although we use the terms Large Urban, Large Suburban, Smaller Metro, and Rural to classify entire counties, there may be urban, suburban, or rural areas within any county. Large Urban counties can include suburbs as well as city centers. Large Suburban counties may also include rural areas. These characteristics should be taken into consideration when looking more closely at individual counties.

Key Findings

  • Rural counties have consistently had the highest premature death rates and, following a few years of improvement, overall rates of premature death are increasing.
  • Nearly one in five Rural counties has experienced worsening premature death rates over the past decade.
  • Large Urban counties have seen the greatest declines in premature death rates since the late 1990s.
  • Unlike other types of counties, nearly all Large Urban counties have consistently shown improved premature death rates.
  • There is no single factor that explains the significant differences in health between Rural and other types of counties

1 There were no Major Urban counties with worsening rates. Totals do not sum to 100% because death rates stayed the same in some counties.

Key Health Factors by Level of Urbanization

As the County Health Rankings model shows, there are many things that influence health outcomes including health behaviors, clinical care, social and economic factors, and the physical environment. Here we show differences across the four types of counties for selected measures within each of these groups of health factors. Looking at Adult Smoking, for example, we find that Large Urban counties have the best (lowest) rates of adult smoking while Rural counties have the worst (highest) rates. However, no single factor alone explains the significant differences in health between Rural and other types of counties.

How Do Health Gaps Between Counties Differ By State?

Our country has achieved significant health improvements, driven by progress in automobile safety, better workplace standards, reductions in smoking and infectious diseases, and a host of other advances. But when we take a closer look at this progress, we see that it is uneven. It is clear that not everyone in the US has a fair opportunity to be healthy.

In 2015, County Health Rankings released a set of 50 Health Gaps Reports showing that opportunities for health differ considerably within states. These health gaps exist across neighboring county lines, or within a community among various groups, such as by race, ethnicity, age, income, education, or sexual orientation. To build a Culture of Health for everyone, it’s important to begin closing these gaps. Along with snapshots of the differences among counties within states, the reports offer strategies to help do so.

Below we build on the Health Gaps Reports by taking a closer look at the size of the health gaps within states for three selected measures: adult obesity, the uninsured, and children in poverty.

  • Each circle on the maps represents a state.
  • The color shading of each circle shows how well each state is doing overall (state average). States with less shading are doing better overall. States with deeper shading are doing worse.
  • The size of each circle shows how wide the gap is within the state (state gap). Smaller circles represent a smaller gap between the counties with the best and worst values.2 Larger circles represent larger gaps.

So, small and lightly shaded circles represent the states with the best performance overall and the smallest gap between counties. For example, the adult obesity map below shows that New Jersey has one of the best rates of obesity (lightly shaded circle) and has a relatively small gap in obesity rates between its counties (smaller circle). Alabama, by contrast, has one of the worst rates of obesity (deeply shaded red circle), and a very wide gap in obesity rates between its counties (larger circle).

2 In calculating the size of the gaps for each state, we calculated the difference between the best and worst county values for each measure. The best and worst values were represented by the top and bottom 10% of county-level values for a given measure.

To learn more about how states and local communities can take action to reduce these gaps, visit What Works for Health, which includes a wide variety of evidence-informed policies, programs, and system changes to improve health for all.

What Are The New Measures Of Each County’s Health?

The Rankings are calculated using 35 measures (5 health outcomes and 30 health factors). There are additional measures that are not included in county ranks because some measures, like demographics, provide good contextual information but do not lend themselves to ranking. Other measures are not available for a majority of counties, but also provide helpful context for understanding a county’s opportunities for improving health. We highlight three of the new additional measures for 2016 below.

Residential Segregation

Residential segregation refers to the degree to which two or more groups live separately from one another in a geographic area. Residential segregation of blacks and whites is considered to be a fundamental cause of health disparities in the US and has been linked to poor health outcomes including greater infant and adult mortality, and a wide variety of reproductive, infectious, and chronic diseases. Although most overtly discriminatory policies and practices promoting segregation, such as separate schools or seating on public transportation or in restaurants based on race have been illegal for decades, segregation caused by structural, institutional, and interpersonal racism still exists in many parts of the country. Segregation continues to have lasting implications for both personal and community well-being.

No single strategy can lessen the potential negative health impacts of residential segregation. Rather, a range of policies, programs, and systems changes, such as affordable housing development incentives, better enforcement of fair housing policies, and public transit system expansion to connect neighborhoods and resources are good examples of ways to address the differences in housing and environmental quality, as well as economic and educational opportunities that exist in many segregated neighborhoods.

Key Findings

  • Black/white residential segregation values are highest in the Northeast and Great Lakes region and lowest along the Southeastern seaboard.
  • Among counties in the US, the average black/white residential segregation value is 46.
  • The best performing counties have black/white residential segregation index values of less than 23.
  • The worst performing counties have black/white residential segregation values of at least 67 or higher, meaning that at least 67 percent of either blacks or whites would have to move into other census tracts to create an evenly distributed residential population.

Understanding The Measure

The black/white residential segregation index3 can range from zero (complete integration) to 100 (complete segregation). Anything above 60 represents extremely high segregation.

The black/white residential segregation measure is only available for counties with a black population of at least 100. Thirty-five percent of US counties (shaded in gray) have a black population of less than 100 people and are therefore not provided with black/white residential segregation data.

The makeup of local populations varies across the US and so we provide both black/white and non-white/white residential segregation data. For example, in Nevada or Idaho (which both have relatively smaller black populations compared to other states), it might be more helpful to look at non-white/white segregation, rather than black/white segregation. It is also important to consider that for some population groups, such as new immigrants, living among others who share their cultural beliefs and practices can help build social connections that can lessen the health risks of hardship and neighborhood disadvantage.

3 To measure residential segregation, we use data that show the evenness with which two groups (i.e. blacks and whites) are distributed within census tracts across counties. The index score is the percentage of one of the two groups that would have to move to different census tracts in order to produce a distribution that matches that of the county.

Drug Overdose Deaths

The US is experiencing an epidemic of drug overdose deaths. Since 2002, the rate of drug overdose deaths has increased by 79 percent nationwide, with a 200 percent increase in deaths involving opioids (opioid pain relievers and heroin) since 2000. Drug overdose deaths are the number of deaths due to drug overdose or poisoning per 100,000 population. These deaths include unintentional, intentional, and undetermined poisoning by and exposure to either prescription, over-the-counter, or illegal drugs.

Key Findings

  • Among counties in the US, the average rate of drug overdose deaths is 13 per 100,000 people.
  • Nine percent of counties have drug overdose rates of 6 per 100,000 or lower.
  • Sixteen percent of counties have drug overdose death rates above 20 per 100,000 with some counties having rates as high as 85 per 100,000.
  • Drug overdose deaths appear highest in Northern Appalachia and in parts of the West/Southwest, lowest in the Northeast, and higher in rural counties than in other types of counties.

Insufficient Sleep

Sleep is an important part of a healthy lifestyle. Sleep plays a key role in maintaining proper growth and repair of the body, learning, memory, emotional resilience, problem solving, decision making, and emotional control. A lack of sleep can have serious negative effects on health. Ongoing sleep deficiency has been linked to chronic health conditions including heart disease, kidney disease, high blood pressure, and stroke, and psychiatric disorders such as depression and anxiety, risky behavior, and even suicide. And a lack of sleep cannot only affect people’s own health, but also the health of others. Sleepiness, especially while driving, can lead to motor vehicle crashes and put the lives of others in jeopardy. Our measure of insufficient sleep is the percentage of adults who report getting fewer than 7 hours of sleep per night on average.

Key Findings

  • Among counties in the US, on average, 33% of adults do not get enough sleep.
  • The rate of insufficient sleep in US counties ranges from 23 percent to 47 percent.
  • Rates of insufficient sleep appear highest in Southeastern US and lowest in the Plains states.
  • There are no significant differences among rates of insufficient sleep by urban/rural county type.
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Recommended citation

University of Wisconsin Population Health Institute. What Works? Strategies to Improve Rural Health. July 2016.

Lead Authors

Alison Bergum, MPA
Bridget Catlin, PhD, MHSA
Julie Willems Van Dijk, PhD, RN
Karen Timberlake, JD

This publication would not have been possible without the following contributions:

Research Assistance

Marjory Givens, PhD, MSPH
Lael Grigg, MPA
Bomi Kim Hirsch, PhD
Amanda Jovaag, MS
Jessica Rubenstein, MPA, MPH
Jessica Solcz, MPH

Outreach Assistance

Matthew Call
Megan Garske

Communications and Website Development

Forum One

Robert Wood Johnson Foundation

Katrina Badger, MPH, MSW
Abbey Cofsky, MPH
Andrea Ducas, MPH
Michelle Larkin, JD, MS, RN
James Marks, MD, MPH
Joe Marx
Dwayne Proctor, PhD
Donald Schwarz, MD, MPH, MBA
Amy Slonim, PhD
Kathryn Wehr, MPH