Unincorporation in counties as a political determinant of health: An exploration of five states

Cristina Gomez-Vidal; Ashley N Palmer; Katherine Kitchens; G Allen Ratliff; Genevieve Graaf

doi:10.1016/j.ssmph.2024.101728

Unincorporation in counties as a political determinant of health: An exploration of five states

SSM Popul Health. 2024 Nov 19:28:101728. doi: 10.1016/j.ssmph.2024.101728. eCollection 2024 Dec.

Authors

Cristina Gomez-Vidal¹, Ashley N Palmer², Katherine Kitchens³, G Allen Ratliff⁴, Genevieve Graaf³

Affiliations

¹ School of Social Welfare, University of California, Berkeley 120 Haviland Hall, Berkeley, CA, 94709, USA.
² Department of Social Work, Harris College of Nursing & Health Sciences, Texas Christian University, 2800 South University Drive, Fort Worth, TX, 76109, USA.
³ School of Social Work, University of Texas at Arlington, 501 W. Mitchell Street, Arlington, TX, 76019-0129, USA.
⁴ School of Social Work, University of Nevada, 1664 N. Virginia Street, Reno, NV, 89557, USA.

Abstract

Local government policies and practices shape the context of the places that can alter a population's life chances through socioeconomic factors, built environments, and healthcare access. County governments, one of the most ubiquitous U.S. political structures, impact health outcomes within their jurisdiction through multiple policy levers and pathways. By identifying which political determinants within counties are associated with variation in life expectancy and premature death, we can better intervene on modifiable factors. One overlooked political determinant from public health studies is the county's responsibility as the primary local government for approximately a third of the U.S. population and 93% of land in unincorporated areas. To conduct an ecological study and assess associations between county population health and county responsibility for unincorporated areas and populations, we created and tested two county indicators of unincorporation. Multilevel multivariable regression results showed that larger proportions of unincorporated land within a county are associated with lower average county life expectancy. More testing of the measurement is needed to understand the relationship between unincorporation, county government, and population health outcomes.