Like real estate, when it comes to your health, it’s all about location, location, location.
The 2016 County Health Rankings, released Wednesday, compare health disparities among nearly all the counties in the country on the basis of more than 30 factors, including education, housing, exercise and commuting time. The report shows dramatic differences between rural and urban counties on a number of measures, most notably premature death rates.
Rural counties have higher rates of smoking, obesity, child poverty and teen births, as well as higher numbers of uninsured adults than their urban counterparts, according to the report, a collaboration between the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute. Large urban counties have lower smoking and obesity rates, fewer injury deaths and more residents who attended some college.
“What we think is going on here is that … in rural areas, there is a smaller population, fewer businesses, fewer taxes — and they’re struggling to offer as many opportunities as urban,” said lead researcher Bridget Catlin. “All of this has a significant impact on health.”
There are 3,141 counties (and county equivalents) in the United States, according to the U.S. Geological Survey. Catlin’s team ranked all but about 100, explaining that if a county’s population is too small, it’s difficult to get reliable data; the numbers fluctuate so wildly that publishing them could be misleading.
Furthermore, Catlin’s team only ranks counties within states and does not make a list of the most and least healthy counties in the country. That’s because it’s most helpful for communities to compare themselves with others in their own state, operating in the same geopolitical and cultural environment, she said.
“Urban residents definitely have better access to health care, but there’s far more to good health than just that,” said Catlin. “People have an impression of rural areas as healthy living and the great outdoors, but there aren’t sidewalks. It can actually be more difficult to get out and exercise. Urban can offer more recreation facilities and more safe options.”
“Rural populations are also aging faster than urban areas,” said Catlin. “Younger people who do go to college and leave home — many of them don’t return back home. What’s left is an older population in the rural areas.”
Premature death rate
Rural counties have consistently had the highest premature death rates and, following a few years of improvement, overall rates of premature death are increasing there, according to the report. In fact, nearly one in five rural counties have experienced worsening premature death rates since the late 1990s. Large urban counties have seen the greatest declines in premature death rates, with nearly all showing consistently improved rates.
There is no single factor that explains the significant differences in health between rural and smaller metro, large suburban and large urban counties, according to the researchers.
Catlin’s team defined premature death as death by any means before the age of 75. “We look at the number of years of life lost and more heavily weight deaths at an earlier age, because they’re typically more preventable,” said Catlin. “When a child dies, you’ve lost their whole life ahead of them. At 74, you haven’t lost as much as a society,” to take nothing away from the pain and suffering endured by family and friends. “At some point, we’re all going to die from something,” she said.
Drug overdose deaths
“This is one where we weren’t very surprised,” said Catlin. “A lot of people have been talking about this. It’s in selected places. We wanted to get out the information more broadly, so more people become aware of this epidemic.”
The average rate of drug overdose deaths in the U.S. is 13 per 100,000 people, according to the report. That includes unintentional, intentional and undetermined poisoning by, and exposure to, prescription, over-the-counter or illegal drugs. 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.
“This is an issue that affects everybody, from all walks of life, and there are things that can be done about this,” said Catlin. “We don’t have to sit back and watch this happen. There are things every community can do to save lives, such as tracking prescriptions, safe disposal of drugs, increased access to prescription medicine that can reduce overdoses, and more training of first responders (on) how to administer those drugs.”
Perhaps most important, she said, is increasing access to mental health services.
Insufficient sleep
“I was surprised to see these numbers — 1 out of 3 adults don’t get enough sleep,” said Catlin. “That’s a lot of people!”
On average, the report said, 33% of adults do not get enough sleep, getting fewer than 7 hours per night, on average. Rates of insufficient sleep appear highest in the Southeast. Residents of the Plains states seem to get the best sleep.
“Sleep is absolutely key to overall health, lost productivity at work, stress, depression and motor vehicle crashes,” said Catlin. “There are things we can do as individuals to increase the amount of sleep we get. Beyond individuals, there are things a county can do, like help people who work long hours to support their families and reduce the need for working multiple jobs to earn a sustainable living, by increasing wages.”
“Primary care physicians don’t necessarily ask us about sleep,” said Catlin. “Some schools are shifting the school day or delaying start time for middle and high school, because we’re learning kids have different circadian rhythms. Employers that run workplaces 24/7 can support better sleep, with things like napping rooms.”
Residential segregation
“Because of historical policies and things like that, we’ve ended up with various groups living segregated from others,” Catlin said. “Particularly for blacks and somewhat for Hispanics too, when they end up in segregated neighborhoods, we see lower housing quality, higher concentration of poverty, less access to quality jobs and education, and less access to a public transit system that allows them to access other opportunities. When living in conditions like this, people experience greater stress, and therefore a higher incidence of illness and death.”
The study found the most extreme residential segregation in the Northeast and Great Lakes regions, and the most integrated counties along the Southeastern seaboard.
The authors note it’s 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.
Searching for solutions
“Ranking communities … is appealing to Americans’ competitive nature,” said Catlin. “The whole point of it is to start conversations that lead to actions that help people live healthier lives. The things we can do on our own are so much easier to do if you live in a supportive community where there are opportunities all around you to make the healthy choice.”
Catlin and her team hope the rankings and raw data will help communities figure out what they’re doing well and where they have room to improve.
The County Health Rankings and Roadmaps program also has an action center to help people get involved, called What Works for Health. “We don’t just provide the names of the strategies,” said Caltin. “We’ve gone into the scientific literature. We looked at the evidence on how well things work, and provide summary ratings and sources, so a community can choose to select something that has been shown to work in other places. But remember, not every strategy works in every community.”
There are things you can do at home with your own kids, said Catlin, such as eating with, reading to and playing with them. You can join the local PTA, get involved in your neighborhood association or encourage your employer to offer workplace wellness activities. You can also reach out to your local policymakers to request and initiate change.
At the end of the day, it’s healthy individuals who make up a healthy community, but also a healthy community that affords us the opportunity to get and stay healthy in the first place.
