By Rachel Crumpler

When one calls the Columbus County Health Department, there’s an automated message narrated by Health Director Kimberly Smith.

The message presents options such as calling 911 for an emergency or entering the four-digit extension for a specific staff member. Right in the middle of the typical menu options, Smith issues a blunt and sobering truth. “The national County Health Rankings report ranks Columbus County as one of the unhealthiest counties in North Carolina for the eighth year in a row.”

Smith is upfront about what ails Columbus County. She knows that she alone can’t move her county up in the rankings, and she wants to empower her community to do their part. 

“Each and every citizen must take responsibility for their own health, set goals and work each day to achieve a healthier lifestyle,” Smith says in the message.

Since 2010, County Health Rankings have been released annually by the University of Wisconsin Population Health Institute and the Robert Wood Johnson Foundation, attracting the attention of state and local health experts.

It’s a metric of health that shows how the state of North Carolina compares to the nation, as well as how counties within North Carolina compare to each other. 

The County Health Rankings assess health behaviors, clinical care, social and economic factors and the physical environment to inform its model of community health. It uses 35 measures to help communities understand how healthy their residents are today and what will have an impact on their health in the future.

Health experts place varying significance on the County Health Rankings, but generally acknowledge they are one set of data to look at to gauge health.

“We are accustomed to seeing them,” said Beth Lovette, deputy director of the NCDHHS Division of Public Health. “They’re not perfect — nothing is — but they do put into perspective this whole piece of health we are trying to solve of where you live, play and pray makes a difference. And they do a good job of teasing that out.” 

How does NC compare to the nation?

The 2022 County Health Rankings & Roadmaps state report revealed that North Carolina is slightly worse than the nation in about two-thirds of the 35 health measures ranked in the report.

North Carolina fares worse in incidences of premature death, sexually transmitted infections and access to exercise opportunities. 

Additionally, the average childcare cost burden, which is defined as the percentage of household income needed to pay for childcare, is 29 percent in North Carolina. That is four percentage points above the national average of 25 percent. Hyde County, a small coastal county with a population of 5,000, has the highest childcare cost burden at 61 percent.

North Carolina fares better than the nation in 12 measures, including fewer reported days of poor physical and mental health, a lower percentage of adults reporting excessive drinking and fewer reported violent crime offenses.

To make communities healthier, the County Health Rankings National Findings report focuses on the importance of pursuing economic security for all. It highlighted the need for North Carolina and other states to have jobs that pay a living wage, affordable and accessible childcare, equitably funded schools and no gender pay gap. 

How are County Health Rankings used?

Key messages the County Health Rankings seek to illuminate are that there are disparities in health based on where one lives, many factors contribute to health and people need to work together to improve the overall health of communities.

These are themes health officials are conveying daily, and the County Health Rankings are a useful measure to look at as local health directors do their work. 

“A lot of things that go into the County Health Rankings are those determinants of health we always want to make sure we're paying attention to, and so it gives us a good reason to take those rankings and say, ‘Here’s why we might need more attention, more staffing, more funding and more infrastructure around public health,’” Lisa Macon Harrison, health director of Granville Vance Public Health, said. 

The data and metrics are fairly simple to understand, making it easy to present to the public and government officials. The rankings can also be cited when writing grant proposals and making funding requests.

That alone, though, is not how health officials gauge the health of their community. 

“It's always wonderful to have data and metrics in hand when we're trying to establish the next year's goals or changes to programs and things like that,” Lillian Koontz, health director of Davidson County, said. “However, while this unique data is pulled from a lot of credible sources and gets all these different measures, it's not enough to just stand alone and cease the other data collection that we do.”

Harrison also turns to other data sources such as Trust for America’s Health’s rankings of per capita spending in public health. Community health assessments conducted by each county are another key source of data.

Amy Underhill, health education supervisor at Albemarle Regional Health Services, a consolidated health department representing eight counties on the coast, said in an email it does not use the ranking changes as a metric to measure progress. 

Overall, the County Health Rankings help drive conversation about where public health can be improved across the state and in counties. But the work of improving is difficult and slow, and it takes more than just the local health departments acting.

“We can go out and talk diet, exercise, alcohol, other substance abuse, safe sex in the schools, but if you don't have good partnership, you're not going to get anywhere in the health rankings,” Smith said.

How do NC’s counties compare?

The report ranked North Carolina’s 100 counties relative to each other in two categories: health outcomes and health factors. However, the County Health Rankings are not reflective of health disparities within counties.

Health outcome rankings were based on length and quality of life. Health factor rankings were determined by community conditions that can affect health and opportunity such as access to quality education, living-wage jobs, quality clinical care, nutritious foods, green spaces and affordable housing.

COVID-19 has added a new dimension to life span, and deaths related to the novel coronavirus recorded through the end of 2020 are reflected in the ranked measure of premature death.

Nearly half of North Carolina’s counties declined in health rankings this year, according to NC Health News data analysis.

From 2021 to 2022, 47 counties fell in health outcomes and 46 counties decreased in health factors.

Chart shows a map of NC counties health outcomes, with the worst health outcomes in dark green
Health outcome ranks are displayed using quartiles on the map. Credit: Screenshot from County Health Rankings NC Report

While there was movement in the rankings, counties in the top and bottom 10 have remained fairly consistent for years. Those at the top are generally wealthier and urban, while those at the bottom are poorer and rural.

For the first six years the report was released, Columbus County, a rural county in southeastern North Carolina without much industry, ranked last at 100, Smith said. She remembers walking into a meeting with all the health directors a few days after the rankings were released one year and said the room went quiet. 

Someone finally asked her, “How does it feel to be number 100?”

“We’ve got no place to go but up,” she responded. “Everybody else has to worry about dropping down.”

Under her leadership, Columbus County has made a slow climb in the rankings, moving to 91 this year.

“Can it be better? Yeah, sure. But it's not anything that you're going to be able to change overnight,” Smith said.

She tries to avoid comparing the status of her county to others as she knows she can only work to improve hers. 

This year, Warren County dropped 12 spots in the rankings to join the bottom 10 in health outcomes. 

Currituck and Cabarrus counties rejoined the top 10 list in health outcomes, after each moving up three spots. They knocked out Polk and Chatham counties from the top 10. 

Wake and Orange counties are consistently in competition for the top spots in both categories.

“When I'm looking at the top 10, I think to myself: Who's that health director? What can I talk with them about? What can I glean from them and bring to Davidson County potentially to improve the health of our citizens here?” said Koontz of Davidson County, which ranks 54 in health outcomes and 59 in health factors this year.

In terms of health factors, Mecklenburg County, the second most populous county in North Carolina, lost its status in the top 10 this year, falling nine spots. New Hanover joined the top after slowly increasing its rank over the past three years from 21 in 2020 to 7 this year.

Bladen and Northampton counties moved up four and five spots just elevating them out of the bottom 10 in health factors. Anson and Tyrell counties moved down slightly, taking their place in the bottom.

Chart shows NC counties health factor rankings, with the worst counties in darker blue
Health factor ranks are displayed using quartiles on the map. Credit: Screenshot from County Health Rankings NC Report

There are regional differences in the rankings, with the rural counties generally placing lower. 

“It’s also a reflection of our local economies,” Harrison said. “Poor and rural areas are going to score less than urban areas that have more infrastructure for public health, more funding to be able to do things.”

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Rachel Crumpler is our Report for America corps member who covers gender health and prison health. She graduated in 2022 from UNC-Chapel Hill with a major in journalism and minors in history and social...