Several years ago the Robert Wood Johnson Foundation made a profound and radical change in its direction. Look into the future and really wanting to make a significant impact on health, they decided to launch a culture of Health Vision. As a part of that vision they partnered with the University of Wisconsin Public Health Institute to create one of the most trusted and well-used sources of population health indicators, the county health rankings and roadmaps. In this module, we're going to explore the county health rankings approach. We're going to demonstrate some of the health outcomes and health factors and those rankings in Michigan as an example. We're going to begin to construct a view where Michigan counties might prioritize action to improve their population health. So the county health rankings and roadmaps this collaboration with the Robert Wood Johnson Foundation has some major goals underneath of it. The first is to build awareness, awareness of the health outcomes and health factors and communities. They want this to be a major reliable sustainable source of local data, and it is. They also want this to be so easy to use that they can engage and activate local leaders from all different parts of the sort of community fabric. And they want this to be accessible to connect and empower community leaders. So they make the data not only accessible, easy to use but beautiful and I'm going to give you some examples of that. Underneath of this mindset of being able to provide data that people can use is some education in there about really what they're looking at. Because when we think of the data that we're looking at today, it's really about the health outcomes the state of the health of the community. When we look at health factors it really is a projection out into what tomorrow's health is likely to be. Because these health factors, the social determinants of health in particular are ways in which you can sort of see the whole population is going to be, I'm going to say confined to options. So the county health rankings and roadmaps always has this stance of looking at what's happening now and what's likely to be influencing the health of tomorrow. So here's two examples. I went onto the website and it literally took me just 14 seconds to type in Michigan, ask for the county health rankings in my state and it generated these two amazing maps. There's a health outcomes ranking and a health factors ranking where I can go in and I can see individual counties and basically are they at the top or at the bottom of the rankings for health outcomes and health factors. Both of these are representing indices across many different indicators. And in a moment I'm going to go through some of those indicators that end up being summarized in this one snapshot that really is quite a good snapshot, that tells you a little bit about the health of these counties. In the next 15 second on the website, I went and asked for an annual report for Michigan. And here is just one graphic that I got out of this larger report that I wanted to show you is just a beautiful illustration of health information communicated in a way that people can see quite a bit of detail, but then also the implications of those numbers. So you can see in the banner it says in 2017 in Michigan more than 410,000 children lived in poverty. So that right there, that who, what, when, where kind of approach and it's focused on giving people an idea of the number of children. So numbers like that tell people wow, we've got a lot to do because if we're going to create a system that is for 400,000 children. We're going to need something that is of a certain size and shape that's different than if you only have a 100,000 or if you have a million. The next thing that they do is provide kind of insight into some of the implications of that. So in the panel that says 48% of Michigan's children in poverty were living in a household that spends more than half of its income on housing costs. You start to see so that's half of the children in poverty that actually live in households that are not going to have money for some essentials. And what are those essentials? Well, that's in the next panel where they make it very explicit when they say leaving little left over for other essentials, like healthy food, transportation and medical care. Overall, this is just an incredible resource. If you want to translate numbers and data into something people can see what does it mean? And what should we do? And what is the consequence if we don't do things? So going down into the county level information can also be quite useful. So here is the complete list of Michigan counties and the side-by-side ranking for the health outcomes, which are in orange or red and in green the health factors. So how do you read this? If you look at Alcona they're 76th on the health outcomes, so they're actually kind of at the lower part of the distribution of ranks. So they're not doing all that great on the health outcomes indices. On the health factors they are ranked 43, so that's kind of like right smack in the middle/. But you could look at any of these counties and start to see they're either doing really well on both, really not well on both. Or they've got some kind of disparity between a health outcome in a health factor. And those kind of give you some ideas, for instance of where you might at eyes actions, if the health outcomes are good but the health factors aren't, then focus on the health factors and vice versa. So now I want to go into some of the actual data inside of the county rankings that's possible to get. Because rankings have limitations, some of the biggest limitations are that you can't really see. Well, is everybody doing really well and they're still just the ranking from 1 to 83 in Michigan? Or is it everybody's doing badly and they're ranked 1 to 83. So in a table like this the county health rankings and roadmaps provide both the measures a good description a way to compare the US to the state to the overall statistics and averages. And then also a comparison between the top and the lowest sort of the min and the max of the Michigan counties. So what are some of the health outcomes that are going into that health outcome index? Well, it's things like premature death, that's the years of potential life lost or the percent of adults reporting fair or poor health. So that's kind of their in the low health part of the spectrum. The average number of physically unhealthy days or the average number of mentally unhealthy days reported in the last 30 days. So this is getting two more of the World Health Organization's definition of health of physical, emotional and mental well-being. And then the percent of live births with low birth weight. These are all really good indicators of the health of a community. And by being able to see the US versus the state, the min versus the max, you can start to basically see well as my county doing okay? Are we basically at the norm? Or are we way at one tail of the distribution of the other? I know for some people that looking at numbers and tables like this can be completely not mind-numbing, but for others it can be an incredible experience. So for me if I take the time to sort of stop and quiet my mind and let the numbers turn into people but those numbers turn into places. I can start to see patterns and my mind starts to fill with questions, like what's causing this disparity? Or wow, that community is doing really well, I wonder what making such a big difference. And in those moments all their doors open up to for instance picking up the phone and calling somebody, or looking a little bit more deeply into what is working. Or for instance if it's in my own county, well, what is it that I can lend my efforts to to improve things? So here are some data about the major health factors. These are things that most of us are aware of like the percent of adults who are current smokers or the percent of adults to report a body mass index over 30. It's also things like index of factors that contribute to the healthy food environment. Or the percent of adults that are reporting no leisure time, that's relationship to physical activity is one of the biggest precursors to whether or not somebody develops chronic diseases early. Also, the percent of the population with adequate access to locations for physical activity. Because if you can't go out and exercise well, that particular avenue towards health is cut off. and also we want to look at percent of adults that are binge drinking or heavy drinking because of the way in which it has an effect on all of the body, the mental health and so forth. Another big indicator of major health factors is the percent of driving deaths from alcohol involvement. Or the number of newly diagnosed chlamydia cases, so sexually transmitted infections are a big part of the health factor profile. And the percent of births that are associated with teenage pregnancies. So if we go over and look at the US versus Michigan and we look perhaps at the adult smoking and obesity. You can see that Michigan has a little bit more in terms of both smoking and obesity than the US. And if you go to the next set of rows where we're looking at food environment or physical inactivity, we're not doing any worse than the US and so forth and so on. Mostly the US and Michigan tends to be kind of a line because these are averages of very large populations and Michigan is in US. So we've got many of the cultural norms. And so while we have some let's say health outcomes are factors that we might be outliers on. In general means are going to be within, you know, kind of close proximity. But if we look at the mins and the max of the counties we can start to see much wider variation and I pulled out a few to sort of demonstrate what I mean. So if you look at the access to exercise opportunities the percent of the population with adequate access to locations for physical activity. There's at least one county where only 10% of the population has adequate access. That's huge, what is going on there? Is it that it's not safe? Is it that there's no infrastructure for it? So it's almost like they have no place that they can go and exercise, there's got no accessibility. Whereas the maximum there, which I didn't circle is 99%, so there are some counties that everybody feels like they've got adequate access. If we move down and look at some of the other wide differences like the percent of driving deaths from alcohol involvement. There's one county that 67% of the driving deaths are associated with alcohol. That's a major issue, that means that people are drinking and driving much more frequently. And what's going on there? Is there not that sort of emphasis or the cultural norm that says if you've been drinking don't drive? That might be an easy thing to actually start to I'll call it tip the balance on if that it exists and it's a major factor, and so on and so forth. You can look at any of these with the eye of saying well what counties are really very very far from a min? And probably our indicators where we need community health improvement. another major part of this whole examination of a county's health outcomes and their health factors is basically their access to clinical care. So the percentage of the population that's uninsured or the ratio of primary care physicians to the population. Likewise the ratio of the population to dentists or to mental health providers. Because all of these are indications of the ability to get the care that you need when you need it. Another good indicators the percent of hospital stays for ambulatory care sensitive conditions, which is a whole big mouthful really pointing to preventable hospital stays. So how many hospital stays could have been prevented? Also things that are in the preventive space of mammography and flu vaccinations, especially, if you think about the percent of Medicare enrollees, these are people that are over 65 for instance. Flu is one of the major culprits and sending older people to the hospital or into getting pneumonia and dying. So these two preventives are an important part of sort of the snapshot of clinical care and within any kind a county. Again, if we look at US and Michigan, there are some differences they're not huge. But when you start to look at the counties again, you've got very large differences in some of the areas. So I draw your attention to the the ratio of the population to primary care physicians. In one Michigan County it's 11,500 to 1 position, that's amazingly sparse. And then another county it's 580 to 1, which is incredible. And the same goes with mental health providers or for instance the preventable hospital stays. There's one county where they're very sort of frequent and an another where it's not at all. So this looking in would provide an ability to prioritize and rank because not all of the clinical care indicators and access indicators say that there's a problem. But those that do probably that's a good place to start to focus. Next, we're going to look into the social and economic determinants of Health in Michigan. So this is things like the education of Michigan citizens, like the percent of ninth grade cohorts that go on to graduate in four years, they're going to finish their High School degree. Or the percent of adults that are getting some kind of post-secondary education beyond high school. Or those that are actually unemployed nut that are seeking work. And the percent of children under 18 that are in poverty. This is a major pre-cursor to sort of adulthood poverty and other sort of consequences you can think of that has to do with mental emotional and physical health. Then another important indicator is the ratio of income between the 80th percentile and the 20th percentile, that gap. And what is that gap look like in Michigan? Or the percent of children that live in a household headed by a single parent. So single parenting has a lot of stressors with it, and one of them is income and the other one is the ability to basically care for many children. So when we look at one of the social determinants, we want to just know what's the number of households where they don't have to supportive adults. Another thing is a number of membership associations per 10,000 or the amount of violent crime or the deaths due to injury. So all of these are important socio-economic determinants of health and there are a few of the Michigan counties that are doing really well or really poorly on these elements. And if I was going to do a community health needs assessment these might be some of the top things that I could see that are contributing to downstream health outcomes that are not particularly good. Last but not least the county health rankings also has some very good physical environmental factors that you can look into. Things like the air pollution, or the drinking water violations, or severe housing problems, or issues with driving and commuting, which both influences air pollution. But then also tends to be socially isolating as well as taking a toll on the amount of time that you have for physical activity. And again, there are a few outliers. And some of the Michigan counties that are way beyond what you would think of as the average free that the US or Michigan itself. There's so much more to County Health rankings website than what I was able to show you here. You can get detailed data about a single county. So those same kind of tables you can get for a single county and you could compare just your county and the county next door or a few counties. I mean the data is there and is easy to access. They also have really great built-in supports for communities to take this data and turn it into presentations or plans for change. And so I really hope that you get a chance to work with this website really closely. It's incredibly rich and we are incredibly lucky to have fast access to such high quality data.
