Population Health

Population health has become a focus for public health and many health systems. Improving population health is one of the key components of the Institute for Healthcare Improvement’s Triple Aim Initiative. According to David Kindig, population health is defined as the health outcomes of a group of individuals and includes the distribution of such outcomes within the group. Improving population health requires attention not only to improving the overall health of a population, but reducing disparities between groups within a population.


Life expectancy in the region is a prime example of the distinction between overall health outcomes and their distribution. Data for the metropolitan region’s population indicates that residents tend to live longer than the average American. However, life expectancies in the region varies widely depending upon where in the region one lives. The Robert Wood Johnson Foundation found life expectancies to vary by up to 7 years, depending upon where on the metro line one lives; and the Northern Virginia Health Foundation has documented that within Northern Virginia alone, the number of years an average newborn can expect to live varies by as many as 13 years. These disparities can be attributed to a number of health and socioeconomic factors, commonly referred to as social determinants of health (SDOH), including race, education, income, and neighborhood conditions, in addition to timely access to health care services.

For more information on population health in the region, check out the following resources:

Uneven opportunities report

Metropolitan Washington Council of Governments Report on Uneven Opportunities in the Region

The Metropolitan Washington Council of Governments released a report that aims to better understand health status and disparities across the region. The report, Uneven Opportunities: How Conditions for Wellness Vary Across the Metropolitan Washington Region, was produced by the Virginia Commonwealth University Center on Society and Health and analyzed data from 1,223 census tracts in the region, with a focus on life expectancy and other factors that shape health.

Community Catalyst Report on Advancing Health Justice

Community Catalyst, a national non-profit advocacy organization that prioritizes quality affordable health care for all, released a report that makes the case for an agenda to improve the health of Americans. The report, Advancing Health Justice: Building a Health System that Works for Everyone, recommends that a policy agenda aimed a strengthening the “three-legged stool” consisting of coverage, quality, and social determinants of health is the best way to support a health system that works for everyone and achieves equitable health outcomes. Focusing on proactive advocacy and engagement with governments at the state and local levels will help build a more diverse health justice movement as an essential step for transformational change.


County Health Rankings & Roadmaps

The Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute build awareness of the many factors that influence health through their County Health Rankings & Roadmaps program. This initiative provides local data on health factors, including health behaviors, clinical care, social and economic factors, and physical environmental factors; and health outcomes, including measures for both length and quality of life, to help community leaders identify opportunities for improvement.

American Fact Finder

The American FactFinder provides access to data from many censuses and surveys. Search and download local, state, and national data on population and housing; poverty and income; social and education, and other characteristics that are comparable across all U.S. geographies.

(Kevin Harber/Flickr)

Kids Count Data Center

The Kids Count Data Center, a project of the Annie E. Casey Foundation, pools data from national resources, as well as Kids Count state organizations, to assess the health of children in the United States. Visitors to the site can access local, state, and national data on hundreds of indicators affecting child health, including demographics, economic well-being, education, family and community, health, and safety indicators.


State and local Health Departments are responsible for developing Community Health Improvement Plans to systematically address key health concerns identified in each community. State Health Improvement Plans are usually based on health status indicators and community needs assessments. Plans are developed through collaborative processes with key community stakeholders including hospitals, clinics, insurers, professional associations, and community and civic groups with an active interest in community health. In the National Capitol Area, Maryland’s Population Health Improvement Plan and Virginia’s Plan for Well-Being 2016-2020 inform the local health improvement processes conducted in each of its counties. The District of Columbia’s Department of Health has the same responsibility and functions as a state health department. The District of Columbia Healthy Communities Collaborative Health Improvement Plan was completed by a collaborative that included area hospitals and community health centers, in addition to the local health department.


To view county-level Community Health Needs Assessment, Community Health Improvement Plans and other county-level health indicators click on the county of interest on the map.


To learn more about community health improvement planning visit the National Association of County and City Health Officials.

(Ted Eytan, Flickr)

As the complex interplay of a multitude of factors affects health, addressing population health likewise requires a multi-faceted approach. The County Health Rankings & Roadmaps project includes What Works for Health, which provides communities with the tools for action to implement evidence-informed policies, programs, and systems changes to address population health. Interventions are ranked by evidence base and the strategy’s potential to affect disparities. Additionally, IHI’s 100 Million Healthier Lives project has launched a collaboration platform for local community leaders to promote the sharing of metrics and bright spots, and provides organizations with the tools to analyze the effectiveness of their own interventions, with the goal of 100 million people living healthier lives by 2020.

Salud America! Health Equity Report Card

Get a Health Equity Report Card for your county! The Salud America! Health Equity Report Card generates local housing, transit, healthcare, and other data to identify socioeconomic and health issues in each county. This data is displayed  in the form of an interactive map, through which you can can obtain various equity measures comparing health-related conditions of those who identify as Latino with those who are Non-Latino White. The Health Equity Report Card can be used to help drive community change in your county.

The State of Obesity: Better Policies for a Healthier America

Obesity, a pressing health problem that impacts about one in three Americans, relates to the social and economic conditions in which a person lives. Trust for America’s Health (TFAH) released a report in September 2019 on The State of Obesity: Better Policies for a Healthy America that tracks the latest data and policies and offers recommendations. This report includes an in-depth exploration of racial and ethnic disparities in obesity and advancing health equity. Although there have been positive changes in programs and policies implemented in the last decade, such as healthier WIC food packages and local beverage taxes, more progress is needed. TFAH recommends the following:

  • Strengthen Federal Best Practices to Build State and Local Capacity and Reduce Disparities;
  • Make Physical Activity and the Built Environment Safer and More Accessible;
  • Prioritize Healthy Eating by Making Changes Across the Food System;
  • Change How the Nation Markets and Prices Unhealthy Foods and Beverages; and
  • Work with the Healthcare System to Close Gaps.
TFAH obesity report 2019

Header photo credit: Ted Eytan/Flickr

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