Healthy people and healthy communities are the foundation of a thriving, prosperous state, and improving the health, safety, and well-being of North Carolinians is a core part of the work of state government. In parallel with the national Healthy People initiative run by the United States Department of Health and Human Services, the North Carolina Department of Health and Human Services (NC DHHS) has released Healthy North Carolina (HNC) goals at the beginning of each decade since 1990. HNC is a set of health indicators with 10-year targets designed to guide state efforts to improve health and well-being. Identifying key indicators and targets allows NC DHHS, the Division of Public Health (DPH), local health departments, and other partners across the state to work together toward shared goals.
One of the goals of NC DHHS is to ensure that all North Carolinians have the opportunity for health. Health equity is the opportunity for all people to attain the highest level of personal health regardless of demographic characteristics.1 Health begins in families and communities, and is largely determined by the social and economic contexts (responsible for 40% of the variation in health outcomes) in which we grow up, live, work, and age; the healthy behaviors (30%) that those contexts make easier or harder2; and our physical environments (10%) (Figure 1). Some of the social, economic, behavioral, and environmental factors that affect health include:
safety of families and communities,
exposure to environmental contaminants in air, water, and soil,
quality of housing and education,
access to transportation and healthy food,
availability of employment opportunities and a living wage,
exposure to and use of alcohol, tobacco, and other drugs, and
opportunities for physical activity.
POPULATION HEALTH MODEL
Source: County Health Rankings & Roadmaps, County Health Rankings Model. https://www.countyhealthrankings.org/explore-health-rankings/measures-data-sources/county-health-rankings-model
These factors are called drivers of health (also known as social determinants of health) and they directly affect health outcomes like development of disease and life expectancy. HNC 2030 sets the stage for a focus on health equity and these overall drivers of health outcomes.
Over the past decade, North Carolina's overall health ranking has improved from a low of 37th in 2014 to a high of 31st in 2015 and is now 33rd as of 2018 (ranking of 1st as best and 50th as worst), according to America's Health Rankings. The improvement in ranking is a result of successes in several areas. However, there are some growing challenges in the state that have prevented North Carolina from rising higher. See Figure 2 for examples of these successes and challenges. In addition to the slow improvement in overall health in the state, stark disparities exist, particularly between different racial and ethnic groups. The HNC 2030 group seriously considered disparities and health equity in the selection of health indicators. When available, data on disparities across race/ethnicity, sex, and poverty status are presented in the final report for each indicator.
HEALTH STATUS SUCCESSES AND CHALLENGES IN NORTH CAROLINA
Source: America's Health Rankings (https://www.americashealthrankings.org/explore/annual); Kaiser Family Foundation State Health Facts (https://www.kff.org/other/state-indicator/nonelderly-0-)64/?currentTime-frame=0&selectedDistributions=uninsured&selectedRows=%7B%22wrapups%22:%7B%22united-states%22:%7B%7D%7D,%22states%22:%7B%22all%22:%7B%7D%7D%7D&sortModel=%7B%22colId%22:%22Uninsured%22,%22sort%22:%22asc%22%7D; NC DHHS NC Tobacco Prevention and Control Branch analysis of Youth Tobacco Survey
Note: Data presented in this graphic are the most recent available to compare to national average.
THE HNC 2030 TASK FORCE
The HNC 2030 process from January-August 2019 integrated input from a Task Force, four work groups (Social & Economic Factors, Physical Environment, Health Behaviors, and Clinical Care), and communities across the state through a series of eight Community Input Sessions. Funding was provided by the Blue Cross and Blue Shield of North Carolina Foundation, The Duke Endowment, and the Kate B. Reynolds Charitable Trust. Participants considered several priorities during the HNC 2030 process. Because the HNC 2030 indicators represent issues across many sectors of society, it is important that they be understandable to a broad audience. Each indicator is measurable using existing data sources. The group had a preference for data measured at least every three years to allow for monitoring between now and 2030. When possible, there was also a preference for data available at the county level to allow for local goal setting and local action as well as comparisons within the state. In addition, the Task Force tried to align with statewide health improvement plans and measure sets when possible, including the Early Childhood Action Plan, the Opioid Action Plan, the Perinatal Strategic Plan, and the Medicaid Transformation Quality Strategy. The Task Force and work groups prioritized health equity by selecting indicators related to health disparities within the state.
Overall, 21 health indicators were chosen across the topics of Social & Economic Factors, Physical Environment, Health Behaviors, Clinical Care, and Health Outcomes (Table 1 and Figures 3-4). While the indicators selected for HNC 2030 are all important for North Carolina's population health status, they are not the only important health indicators for the state. HNC 2030 indicators were selected to represent a broad range of important issues for health in North Carolina and oftentimes represent larger issues. For example, primary care providers per population and health insurance status are indicators of broader health care access issues but are not the only important characteristics of that access.
2018 INFANT MORTALITY RATES ACROSS POPULATIONS IN NORTH CAROLINA AND DISTANCE TO 2030 TARGET
2018 LIFE EXPECTANCY (YEARS) ACROSS POPULATIONS IN NORTH CAROLINA AND DISTANCE TO 2030 TARGET
Source: See full Healthy North Carolina 2030 report for information on data sources at www.nciom.org.
W = white; B/AA = Black/African American; H/Lx = Hispanic/Latin(x); A/PI = Asian/Pacific Islander; AI = American Indian; 2016-18 average;
HEALTHY NORTH CAROLINA 2030 HEALTH INDICATORS AND DATA (TOTAL NC POPULATION, 2030 TARGET, AND DATA BY RACE/ETHNICITY, SEX, AND POVERTY LEVEL)
Along with the selection of health indicators, the HNC 2030 group set targets for change. The group reviewed data across several years, any sub-population data available, forecasted values for North Carolina based on historical data, comparisons to other states and among counties within North Carolina, and any relevant targets for health indicators used at the national level (i.e., Healthy People 2030). The group also discussed the potential for movement in each indicator, what is currently being done at community and state levels, what political will and public interest exist to create change, and whether there is funding for the work needed to create change. In some cases, the targets chosen by the group are ambitious. While reaching the selected targets by 2030 is the goal, turning the trend and making improvements toward the goal by 2030 will be considered a success.
NEXT STEPS
The NC DHHS, DPH, and local health departments will remain at the forefront of HNC 2030 efforts; however, they cannot achieve these goals alone. HNC 2030 should be more than goals for public health; it should be goals for the whole state. The inclusion of factors traditionally outside the sphere of public health (e.g., education, employment, housing) means that achieving the HNC 2030 goals will require engaging partners across multiple sectors to improve population health and drive health equity over the next decade.
As the new decade begins, the NC DHHS and DPH will be developing a population health improvement strategy and resources to be used at the local level. The broader view of the drivers of health and well-being with attention to health disparities is an exciting step toward making North Carolina a place for everyone to live a healthy life.
ACKNOWLEDGMENTS
The work of the Task Force would not have been possible without the hard work of the dedicated people who volunteered their time to serve on the Task Force, Work Groups, and Steering Committee, as well as the individuals who participated in the Community Input Sessions across the state
Footnotes
↵1 https://www.ncdhhs.gov/about/dhhs-mission-vision-values-and-goals/mission-vision
TASK FORCE MEMBERS: Ronny Bell, PhD, MS (co-chair); John “Jack” F.A.V. Cecil, MIM (co-chair); Laura Gerald, MD, MPH (co-chair); Elizabeth Cuervo Tilson, MD, MPH (co-chair); Sheryl Bedno, MPH, MS, MD, DrPH; Amy Belflower Thomas, MHA, MSPH, CPH; Battle Betts, MPA; Leslie Boney; Wanda Boone, PhD (co-leader: social & economic factors work group); Vickie Bradley, RN, MPH; Alisahah Cole, MD (clinical care work group representative); John Eller, MBA (social & economic factors work group representative); Vanessa Ervin, MBA; Myron Floyd, PhD, MS (co-leader: physical environment work group); Ophelia Garmon-Brown, MD (social & economic factors work group representative); Nicole Hiegl; Kendra Johnson, MPA; Randy Jordan, JD, MPA (co-leader: clinical care work group); Susan Kansagra, MD, MBA (co-leader: health behaviors work group); Jay Leggette; Magbis Love, MHR; Jim Martin, MS (health behaviors work group representative); Andrea Martinez; M. Leah Mayo, MPH, MCHES (physical environment work group representative); Sara McEwan, MD, MPH (health behaviors work group representative); Larry Michael, REHS, MPH (co-leader: physical environment work group); Sandy Mort, MS, PhD (physical environment work group representative); Danya Perry, MA (social & economic factors work group representative); Carrie Rosario, DrPH, MPH, CHES (co-leader: health behaviors work group); Margaret “Maggie” Sauer, MHA, MS (clinical care work group representative); Jeffrey Spade, MHA, FACHE; Donnie Varnell (co-leader: social & economic factors work group); Kia Williams, MD, MSPH (co-leader: clinical care work group); Ciara Zachary, PhD, MPH
WORK GROUP MEMBERS: Health Behaviors: Donna Albertone, MS; Alice Ammerman, DrPH; Tanya Bass, MS, MEd, CHES; Phil Daye, MS; LaPonda Edmondson, DrPH, MHS; Scottie Gaskins, MEd; Morgan Gramann, JD; Lynne Grey, MA, LPC, LCAS, CSI; Audrey Hardy, MSN; Tracie Heavner, MPH; Kody Kinsley, MPP; Suzanne Lazorick, MD, MPH, FAAP; Layton Long, REHS, MSA; Victoria Mobley, MD, MPH; Zo Mpofu; Heather Murphy, CFRE; Christine Pernell; Scott K. Proescholdbell, MPH, Michelle Reese; Carol Runyan, PhD, MPH; Joseph Skelton, MD; Glorina Stallworth, BSW; Sarah Zoubek, MEM; Clinical Care: Cherry Beasley, PhD, MS, FNP, RN, CNE; Seth A. Berkowitz, MD, MPH; Anna Boone, RN, BSN, MSPH; Michelle Bucknor, MD, MBA, FAAP; Darryl Childers, MPP; Frank Courts, DDS, PhD; Kelly Crosbie, MSW, LCSW; Doyle “Skip” Cummings, PharmD; Robin Fox, MSN, RN, ACM-RN; Suzanne King, MPH, André Logan; Wanda Nicholson, MD, MPH, MBA; Bryan Parrish, MA; Marilyn Pearson, MD; Lisa Renfrow, MSN, RN; Sy A. Saeed, MD, MS, FACPsych; Jennifer Schroeder Tyson, MPH, Melissa Selby, MSW; Lisa Shock, DrPH, MHS, PA-C; Janeth Tapia; Hugh Tilson Jr., JD, MPH; Julia Wacker, MSW, MSPH; Charlene Wong, MD, MSPH; Social & Economic Factors: Carolyn Allison, MPH, Shorlette Ammons; Kia Baker; David Beck, BA; Michael Becketts, MSW, MS, MEd; Olivia Collier, MPA; Henry Crews; Brian Ellerby, MSPH; Ellen Essick, PhD; Charmaine Fuller Cooper, MPA; Mackenzie Harkey, MSPH; Tara Kenchen, JD; Andrea Korte; Roger Manus, JD; Rebecca Planchard, MPP; LaVerne Reid, PhD; Micki Sager, BS; Stacie Saunders, MPH; Stephen J. Sills, PhD; David Sousa, JD, MBA; Vivian St. Juste-Schweizer, MPA; David Tillman, PhD; Thomas Walker, PhD, MPA; Napoleon Wallace, MBA; Donna White, MSHE; Patrick Woodie, JD; Physical Environment: Donyel Barber; Karen Beck, DVM, PhD; Shannon Binns, MPA; Joseph Furstenberg, MPA; Lindsey Haynes-Maslow, PhD, MHA; Brian Horton, MS; Ed Johnson, ASLA, RLA; Timothy Lawrence Johnson, PhD, MS; Marian Johnson-Thompson, PhD; Lillian Koontz, MPA, REHS; William “Mack” MacDonald, MBA; Michelle Nance, MPA, AICP; Mai Nguyen, PhD, MA; Brian Queen; Peter Skillern, MCRP; Lenora S. Smith, MS; Dale Threatt-Taylor, MEM; Josie Williams
STEERING COMMITTEE MEMBERS: Renee Godwin Batts, RN, MSN; Ronny Bell, PhD, MS; Battle Betts, MPA; Chris Collins, MSW; Gail Cormier; Kathryn Dail, PhD, RN; Merry Davis; Alison Duncan, MPA, Ronald Gaskins, DHA, MBA, MPA; Eleanor Howell, MS; Andrea Radford, DrPH, MHA; Cathy Thomas, MAEd; Julia Wacker, MSW, MSPH; Cornell Wright, MPA
A copy of the full Healthy North Carolina 2030 report is available on the North Carolina Institute of Medicine website: www.nciom.org
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