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Last month, the Tennessee Institute for Public Health released the 2007 health index for each of the state’s 95 counties, providing a snapshot of the population’s overall health, health outcomes and health determinants.

Outcomes show the overall health of a county at the time measured. Determinants function as a predictor for the population’s future health based on 32 indicators. In the category of health outcomes, the Institute focused on three measures: mortality, low birth weight rates and health status while alive. Health determinants covered a broad range of statistical components in four main categories: healthcare, health behaviors, socioeconomic factors and physical environment. Specific measures included access to care, tobacco use, education and poverty rates, air quality, teen birth rate, divorce rate, number of violent crimes, and the number of homes in the county built before 1950, among other influences on health status.

“Health is more than just access to care, although that’s an important component,” said Beth Fuller, DPH, executive director of the TNIPH. She added that looking at a broad spectrum of contributing factors can give healthcare providers and government officials a better picture of what is really happening in their county.

Fuller noted high school graduation rates play a significant role in health. Graduating affords more opportunity to secure a job with health benefits and increases salary potential. On the outcomes side, she said low birth weight was included because of its lifelong implications.

“It puts you at increased risk for later health problems. Low birth weight children are just traditionally not as healthy,” she pointed out.

Not surprisingly, socioeconomic status is tightly interwoven with a county’s ranking.

“There are a lot of different ways income affects health, and not just in the paycheck but in all the things that paycheck buys you,” Fuller pointed out. “The tie between income and health is very clear not only in access to care but in personal behaviors and access to information.”

Williamson County in Middle Tennessee, which has the state’s highest per capita income, ranked number one on the Overall Health Index and placed at the top when rankings were broken down into health outcomes and determinants.

Conversely, Hancock County in the northeastern part of the state ranked 95th in overall health. According to the latest census, Hancock County has the lowest median household income of any county in the state and the 27th lowest in the nation. Nearly 30 percent of the county’s population lives below the poverty line.

With nearly a quarter of their population below the poverty line and a median household income of just over $23,000, Fentress County on the Cumberland Plateau ranked last on the outcomes list (and 62 of 95 on determinants index). To the far west, Lauderdale County ranked at the bottom of the health determinants index (and 84 of 95 on the outcomes index).

“Some of the problem counties range from the northeast corner to the northwest corner. In general, the middle of the state seems to be doing better than the east and west … although that is a big generalization,” Fuller said, adding the caveat.

In addition to socioeconomic factors, she said cultural norms also play a key role in health status.

“There’s a cultural context in which people live. A program that might work in one county wouldn’t work in another,” she said.

For example, Fuller noted, when access is taken out of the equation, such as by offering free mammograms to all women, African-American women still took advantage of the offering less than Caucasian women. Fuller pointed out that historically many African-American women have seen cancer as a death sentence whereas more white women had knowledge or experience in effective treatments. Addressing the perception, therefore, becomes as important as offering the service.

Fuller noted TNIPH did not do any of the data collection for the rankings. Rather, the Institute compiled information from many sources ranging from the Behavioral Risk Factor Surveillance System to the U.S. Environmental Protection Agency to a variety of state agencies including the Department of Health, Department of Education and Tennessee Bureau of Investigation.

She also cautioned that in its second year, these rankings are very much a work in progress.

“We’re still refining sources and data collection,” she explained. “It’s not really indicated that you should compare one year to the next. It really takes five years of stable data points collection … which is the same source … for trend data analysis.”

What the rankings do offer, however, is a snapshot of where we are right now and where we might be headed as a community and state. Fuller’s goal is for the information to spark questions and encourage county leadership to delve further into the report and the data dictionary, which outlines where all the data originated. She added her hope is for the index to become a map leading interested parties to more in depth analysis.

The Tennessee Institute of Public Health brings together different stakeholders to search for innovative solutions to improve the state’s health status. Tennessee moved up one notch to #46 on the United Health Foundation national health status rankings this year. Fuller said the goal is to keep the momentum.

“As local levels get healthier, it will trickle up, and the state will get healthier,” she said. “We’re bringing together a lot of different voices to hopefully direct policy decisions and program decisions to affect our health status on a national level.”



June 2008

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