In a ranking of health outcomes across 49 counties in North Dakota, Grand Forks County came in 21st, while Cass County ranked fifth.

Wells County in central North Dakota earned the top spot on the list, which evaluated health outcomes in terms of life expectancy and quality of life. Traill County, Grand Forks' neighboring county to the south, came in fourth.

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The County Health Rankings and Roadmaps program has been compiling annual health statistics in almost every U.S. county for the past 10 years, said Karen Odegaard, associate researcher with the program. The program evaluated all 53 counties in North Dakota, but four were too small to have "reliable measurements" for health outcomes, Odegaard said.

The program measures quality of life based on residents' self-reported physical and mental health, along with the percentage of children born with low birth weight.

"We think of this as sort of a snapshot of today's health," Odegaard said. "The health outcomes rank is really looking at how long people are living and how well they're living."

Several rural counties near the Canadian border, including Cavalier, Towner and Rolette counties, were ranked near the bottom of the list for health outcomes.

Across the nation, researchers have seen several rural communities struggle with health outcomes, according to Odegaard.

"Part of it goes back to social and economic factors," she said. "And we know that rural communities still are recovering from the recession."

Meanwhile, in Minnesota, Carver County was ranked as the No. 1 county for health outcomes. Carver is home to the city of Chaska, a Minneapolis suburb.

The program evaluated 87 total counties in Minnesota. Clay and Polk counties came in near the bottom of the list, ranking 58th and 71st, respectively.

While Grand Forks County ranked 44th in terms of quality of life, the county came in third for length of life, surpassed only by Cass and Ward counties. What's more, Grand Forks County's health outcome ranking inched up from 24th place in 2018.

"We've had a little bit of improvement, so that's encouraging." said Debbie Swanson, director of Grand Forks Public Health Department. "But in the big picture of things, we used to be much higher in the County Health Rankings for North Dakota. So I think it's good to look back and see where we have been to see where we can be going in the future."

And there may be another bright spot in Grand Forks County. The county has consistently ranked highly in clinical care due to residents' access to primary care physicians, Swanson said.

"We have a low number of people to every primary care physician," she said.

Grand Forks County also has reduced its rate of uninsured residents to 7 percent, according to Swanson.

Factoring in other health stats

The County Health Rankings and Roadmaps program also ranked counties based on a series of "health factors," such as the percentage of residents who smoke. Other factors included adult obesity, physical inactivity levels and teenage births, along with the number of alcohol-impaired driving deaths and sexually transmitted infections.

"These are what we think about as tomorrow's health," Odegaard said. "The health factors are also all looking at a measure that the community can do something about. All of these are modifiable, if you will."

Adult obesity in Grand Forks, Cass and Burleigh counties was below the statewide average, but not by very much. As a whole, 32 percent of North Dakota residents were considered obese, which is defined as having a body mass index greater than or equal to 30. Thirty-one percent of adults in Grand Forks and Cass counties were obese, according to the rankings.

Swanson noted that Grand Forks County is "not doing so well" in the areas of adult obesity and excessive drinking. Roughly a quarter of Grand Forks County residents reported binge or heavy drinking, according to the rankings. That falls in line with the statewide average.

For its part, researchers found 37 percent of Polk County residents were obese, nearly 10 percent higher than the statewide average in Minnesota.

The County Health Rankings and Roadmaps program is a collaborative effort between the University of Wisconsin's Population Health Institute and the Robert Wood Johnson Foundation.

In a statement, Robert Wood Johnson President and CEO Richard Besser said "our homes are inextricably tied to our health."

"Imagine the stress and pain that come with unplanned moves," Besser said.

The housing piece

As part of the program, researchers calculated the percentage of households with at least one of these four major housing problems: high housing costs, overcrowding, lack of kitchen facilities or lack of plumbing facilities. In Grand Forks, 16 percent of families reported having a severe housing problem, versus 13 percent in Cass. Across North Dakota, just 11 percent of households faced these problems.

In addition, 10 percent of North Dakotan households spend more than half of their income on housing, according to the rankings.

"We know a safe, secure, affordable place to call home is foundational for good health," Odegaard said.

She also noted more than 1 in 10 households across the country are "burdened with severe housing costs," which means they spend more than half of what they earn on housing.

"This matters to health because when so much of a family's paycheck goes to rent or the mortgage, it doesn't leave much room in the budget for other essential things that contribute to health, like healthy food, medicine or transportation to work or school."

And this disproportionately affects communities of color, Odegaard added, noting that 20 percent of American Indian households face severe housing costs, versus just 9 percent of white households.

Terry Hanson, executive director of Grand Forks Housing Authority, said housing is a "part of the healthcare continuum."

In Grand Forks, high housing costs remain a continued concern, he said. Nearly half of all Grand Forks residents - 44.6 percent - put more than 30 percent of household income toward rent, according to statistics from the North Dakota Housing Finance Agency.

And that figure grows when evaluating the city of Grand Forks proper, where 47.6 percent of residents devote more than 30 percent of their income toward rent.

"Shelter and food are basic needs," Hanson said. "Shelter is first on my list."

Hanson said soil quality in the Grand Forks area is one of the reasons for the higher housing costs in the region.

"The clays here are different than clays and soils in Fargo, so that adds to the cost," he said. "And the cost of real estate is higher to begin with in Grand Forks, so that drives the cost of all the other property up."

To improve health outcomes in the area, Hanson said he aims to provide medical services on site at The Link, a community center between Cherry Heights and Oak Manor, two properties managed by the housing authority.

"I think the best way to address it would be to go back to the old doctor's-call type situation, where the provider comes to the patient," Hanson said, noting that LaGrave on First - another property managed by the housing authority - has a full-time Altru nurse on site.