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Volume 12, Number 4cropped-graphic-e1423682891979

Paying attention to numbers is pervasive in matters pertaining to health, especially in interactions with physicians. Height and weight, waist circumference, blood pressure, cholesterol, blood glucose (HbA1c for persons with diabetes), and other measures are commonly discussed. Age, another number, is the driving factor for when many immunizations are done or screening tests are conducted. Genetic codes (which may include letters as well as numbers) are increasingly used for precision medicine or gene therapy.

Here are examples of some numbers that are infrequently mentioned in discussions of health: 44124, 44103, 8, 24. 44124 is the zip code for Lyndhurst and 44103 is the zip code for a portion of the Hough neighborhood (on the east side of Cleveland, Ohio), both in Cuyahoga County. The communities are only 8 miles apart. Astoundingly, however, life expectancy in 44124 has been found to be 24 years greater than in 44103!

Increasing attention to health disparities in the United States has led some to conclude that with respect to health, zip code matters more than genetic code. Poor urban areas, such as the Hough neighborhood, commonly have higher rates of infant mortality, more violence, more pollution, less access to grocery stores with fresh produce, and often less health care access than in more affluent neighborhoods.

According to the latest “County Health Rankings & Roadmaps Report” from the Robert Wood Johnson Foundation, Cuyahoga County ranks 64th among Ohio’s 88 counties for health outcomes. Montgomery County, where I live and work, ranks 80th. Nearby Greene County, where Wright State University is located, ranks 17th. One might conclude that moving to a less densely populated area is good for health. However, on a national basis, rural areas are showing a worsening premature death rate, whereas premature death rates in large urban counties are actually improving.

The County Health Rankings consider contributors to health outcomes and quality of life in four categories: clinical care (access and quality), physical environment (air & water quality, housing & transit), social & economic factors (education, employment, income, family/social support, community safety), and health behaviors (tobacco use, diet & exercise, alcohol & drug use, sexual activity). None of these factors alone accounts for differences between counties, or between urban and rural areas, but taken together constitute the health status of communities. The goal of the Rankings is to help communities identify what can be addressed to improve health.

The Robert Wood Johnson Foundation’s model estimates that clinical care (health care) accounts for only 20% of health outcomes. There are other models which suggest that health care contributes only 10% to outcomes. What this means is that social & economic factors, health behaviors, the physical environment, and genetic predisposition are the largest drivers of outcomes. Furthermore, all of these variables interact. For example, health behaviors are affected by social and economic factors (the inverse is also true), and by the physical environment.

Matters of population health must be considered from a broader perspective than just health care access and individual health behaviors. Zip codes represent communities, and the well-being (or lack thereof) of a community on many dimensions does indeed affect the health outcomes of its residents. Efforts to improve the quality of life in one’s community are an important aspect of health promotion.


Paul J. Hershberger, Ph.D.

… is a clinical health psychologist. He is Professor of Family Medicine and Director of Behavioral Science for the Family Medicine Residency Program, Wright State University Boonshoft School of Medicine. His clinical practice includes psychotherapy, consultation, and coaching.




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