Introduction

Imagine a place where everyone has a fair and just chance to lead the healthiest life possible – communities with high quality schools, good paying jobs, access to healthy foods and quality health care, and affordable housing in safe environments. Imagine a place where differences in race, culture, and perspectives are not only tolerated, but are celebrated as fundamental to health and wellbeing. Imagine that this is how we all experience our communities, regardless of where we live, the circumstances we were born into, or how we look. This is the vision of health equity.

The County Health Rankings show that where we live matters to health. This year, we bring new analyses that show meaningful health gaps persist not only by place, but also among racial and ethnic groups. These gaps are largely the result of differences in opportunities in the places where we live. And, these differences disproportionately affect people of color. Discriminatory practices and structural and institutional policies, such as unfair bank lending practices and property tax-based school funding formulas, contribute to the types of racial disparities illustrated in this report.

Summary of Findings

  • After nearly a decade of improvement, there are early signs that the percentage of babies born at low birthweight may be on the rise (8.2% in 2016, a 2% increase from 2014). Low birthweight is a key measure of health and quality of life. Babies are much more likely to be born at low birthweight in some communities than others. In all 50 states, there is a higher percentage of Black low birthweight babies than for other racial groups. These percentages exceed those for low birthweight babies born in the typical bottom performing county in each state.
  • Some places and groups of people have fewer social and economic opportunities, which also limit their ability to be healthy. More than 1 out of every 5 youth in the bottom performing counties do not graduate from high school in four years. For American Indian/Alaskan Native, Black, and Hispanic youth, it is 1 out of 4. In 2016, the unemployment rate for adults in the bottom performing counties was 7.5 percent, more than twice that of adults in the top performing counties (3.2%). American Indian/Alaskan Native and Black adults experienced the highest unemployment rates (10.5% and 9.9%, respectively), while Whites and Asians experienced lower rates of unemployment (4.2% and 3.5%, respectively).
  • Residential segregation provides a clear example of the link between race and place. For instance, in smaller metro and large urban counties, Black residents face greater barriers to health and opportunity. Black residents have higher rates of child poverty, low birthweight, and infant mortality, and lower high school graduation rates than White residents. Black residents are also more affected by levels of segregation than White residents. Black children and youth in more segregated counties fare worse in rates of child poverty and high school graduation than Black residents in less segregated counties.
  • Child poverty rates remain at levels higher than those of the pre-recession era despite declines in recent years. Patterns of recovery vary by both race and place. Child poverty rates have been slow to rebound in rural counties and in those with a greater share of people of color. This is important because we also know that a healthy beginning is essential to a healthy future for our nation’s children.
  • Teen birth rates have been declining across community types and racial groups for more than a decade. Hispanic teens have seen the most improvement with rates falling from 77.7 to 31.9 per 1,000 females, ages 15-19. Black and American Indian/Alaskan Native teens have also seen notable improvements. Yet gaps by place and race persist. For example, teens in rural counties have seen the least improvement and continue to have the highest birth rates, nearly twice the rate of teens in suburban counties. American Indian/Alaskan Native, Hispanic, and Black teens have birth rates twice as high as White or Asian teens.

A Call to Action

This report is a call to action for leaders and community changemakers to take these national findings, dig into local data to better understand the local assets and challenges, and implement strategies to address both place and racial gaps, creating communities where everyone has a fair and just chance to lead the healthiest life possible. Throughout the report you will find references to specific local data resources, evidence-informed strategies, and examples of communities that are working to close gaps in opportunity.

The Intersection of Place, Race, and Health

The County Health Rankings show that meaningful gaps persist in health outcomes between counties across the U.S. in large part because of differences in opportunities for health. As the model on page 3 illustrates, gaps in health outcomes result from differences in the factors that affect our health. Unemployment, lower high school graduation rates, and fewer transportation options make it harder to be healthy.

Gaps in these opportunities disproportionately affect people of color – especially children and youth. Structural racism in the form of unfair systems, policies, and practices, such as residential segregation and inadequate access to quality clinical care, have created barriers to opportunity and good health in many communities of color across our nation. These communities have been left behind and are less likely to be economically stable now, and for generations to come. As a result, there is a clear connection between place, race, and health.

To explore the intersection of place, race, and health in more detail, we show one of the measures that contributes to health outcomes – low birthweight.

Health Outcomes

We measure two types of health outcomes: length and quality of life. For length of life, we measure premature deaths (Years of Potential Life Lost before age 75). Quality of life is based on measures of reported health-related quality of life (overall health, physical health, and mental health) and birth outcomes (in this case, low birthweight babies). Low birthweight babies are infants who weigh less than 2,500 grams (or approximately 5.5 pounds). To learn more about what we rank and why, visit Explore Health Rankings. To find your local data, type your county name into the search box.

Low Birthweight

Birthweight is an important indicator of a healthy start to life and is also a reflection of maternal quality of life. For many years across the U.S., disparities by place and race for low birthweight babies have persisted. Numerous barriers often stand between pregnant women and children and the clinical care and social and economic opportunities they need. Failure to close these gaps in poor birth outcomes has lifelong implications for the health and well-being of children, families, and the nation.

Key Findings

  • Recent data suggest that after nearly a decade of improvement, the percentage of babies born at low birthweight may be worsening (8.2% in 2016, a 2% increase from 2014).
  • Across the U.S., there are communities where babies are much more likely to be born at low birthweight. The percentage of low birthweight babies has been highest for babies born to women in Southwest, Southeast, Mississippi Delta, and Appalachian regions.

Trends in Low Birthweight, 2006 To 2016

Low Birthweight among U.S. Counties, 2010-2016

Pattern of Disparity in Low Birthweight

The graphic below compares the percentage of low birthweight babies within the 50 states by place and by race. The green bars for each state represent the range of low birthweight values between the top and bottom performing quartile of counties and the multi-colored dots are the low birthweight values for each race.

Key Findings

  • The gap between the typical top and bottom performing counties (green bars) in the percentage of low birthweight babies is smallest in Hawaii (7.4% to 8.4%) and largest in Colorado (7.0% to 12.4%).
  • The gap in the percentage of low birthweight babies among racial groups is even wider than between counties. This gap is illustrated by the size of the space between the dots on the chart. The racial gap is smallest in Idaho (6.4% to 8.3%) and largest in Mississippi (6.6% to 16.1%).
  • In all 50 states, the percentage of low birthweight babies born to Black mothers (orange dots) is worse than in the typical bottom performing county (green bars) in their state. However, the opportunity to have a healthy start is not the same across states. For example, the percentage of Black babies born at low birthweight is similar in several states to the overall percentage of low birthweight babies in the typical top performing county in other states.

Pattern of Low Birthweight by Race/Ethnicity and Place Across States

Call To Action

Explore how these national and state trends are playing out in your community. Find your county snapshot (enter your county in the search box at countyhealthrankings.org) and review your Health Outcome data on low birthweight and infant mortality, including data by race. Check with your local health department, hospital, or county government for data on birth outcomes. Work with others to focus on increasing opportunities for mothers and babies to be healthy, such as safe neighborhoods, quality housing, good education, good paying jobs, and access to quality health care.

Bridging the Social and Economic Divide

Social and Economic Factors

Social and economic factors are strong drivers of how long and how well we live. We measure education, employment, income, family and social support, and community safety. Find your county’s data, and data by race for children in poverty and median household income in your county snapshot.

State by state, there are meaningful differences in social and economic factors by place and race, such as community connections and supports, schools, jobs, and safe neighborhoods that are foundational to achieving longer and healthier lives. These factors are also interconnected with many other important drivers of health, such as the ability to access clinical care, transportation, or housing.

Better-educated individuals live longer, healthier lives than those with less education, and their children are more likely to thrive. This is true even when factors like income are taken into account. Employment provides income and, often, benefits that can support healthy lifestyle choices. Unemployment and underemployment limit these choices, and negatively affect both quality of life and health overall. The economic condition of a community and an individual’s level of educational attainment both play important roles in shaping employment opportunities.

Across the U.S., people who live in the bottom performing counties face higher rates of unemployment, lower rates of high school graduation, and lower median household incomes than people in the top performing counties. American Indian/Alaskan Native, Black, and Hispanic people typically face similar, if not greater gaps, in social and economic opportunities.

Key Findings

  • Significant disparities exist in social and economic opportunities among counties. More than 1 out of every 5 youth in the bottom performing counties do not graduate from high school in four years. In 2016, the unemployment rate for adults in the bottom performing counties was 7.5 percent, more than twice that of adults in the top performing counties (3.2%).
  • High school graduation and unemployment rates are worse among counties in the Southeast, Southwest, Appalachian, and Mississippi Delta regions.
  • Gaps are even more pronounced for people of color. For American Indian/Alaskan Native, Black, or Hispanic youth, 1 out of 4 do not graduate from high school in four years. In 2016, American Indian/Alaskan Native and Black adults experienced the highest unemployment rates (10.5% and 9.9%, respectively), while White and Asian adults experienced lower rates of unemployment (4.2% and 3.5%, respectively).

High School Graduation by Racial/Ethnic Groups and Among US Counties, 2014-15

Unemployment by Racial/Ethnic Groups and Among US Counties, 2016

TAKING ACTION

San Pablo is Systematically Striving for Better Economic Equality

San Pablo, CA is a kaleidoscope of people. Residents of Latino descent make up 57 percent of the population. Two out of three residents speak a language other than English at home and 45 percent were born outside the U.S. Having weathered tough times during the recession, residents in this small, working-class city in the San Francisco Bay Area understand the connection between economic well-being and health. Local leaders have made removing barriers to employment and fostering entrepreneurship two of the city’s top priorities – with a focus on ensuring these opportunities are available to everyone. A new Economic Development Corporation, supported and partially funded by the city, is offering services like job skills training and affordable childcare. The city has developed key community assets, such as a new community center and a youth sports park through the use of New Market Tax Credits. San Pablo has also invested in a community schools model and youth leadership development with an eye toward the future, and continues to experience a downward trend in juvenile arrests. In 2011, San Pablo had 139 juvenile arrests, and in 2017, it dropped to 24. Learn more at rwjf.org/prize.

TAKING ACTION

The 24:1 Region in Missouri is Making Children’s Well-Being a Priority

More than 20 municipalities in the inner suburbs of St. Louis, MO – the 24:1 Community – came together with a broad and innovative collective vision: stronger communities, engaged families, and successful children. Mayors meet regularly to share best practices. Police chiefs work together to reach the highest standards of policing. Schools are linked with businesses, nonprofits, early childcare providers, and parents working to fully restore the accreditation its school district lost in 2012. With a total population that is 80 percent Black, communities across the 24:1 region are fostering economic opportunity and advancing health equity simultaneously. For instance, in one municipality, there is now a grocery store in a food desert, a new cinema, a Wealth Accumulation Center that demystifies banking and finance, and other supports for residents. There are early signs of success with increased stability for 98 percent of Beyond Housing families with school-aged children, and significant decreases in infant mortality in key zip codes. Learn more at rwjf.org/prize.

How It's Measured

Residential segregation is measured using the index of dissimilarity where higher values indicate greater residential segregation between Black and White county residents. The residential segregation index ranges from 0 (complete integration) to 100 (complete segregation). In this analysis, we measure residential segregation within smaller metro and large urban counties. To learn more about our measure of residential segregation, visit countyhealthrankings.org/segregation. Find your county’s residential segregation data, and data by race for children in poverty, low birthweight and infant mortality in your county snapshot.

Residential Segregation

Decades of research on residential segregation illustrate the connection between place, race, and health. The U.S. has a long history of racism and discriminatory policies and practices that have limited the opportunities of people of color in choosing where to live. For example, in the 30 years post WWII a federal policy known as “redlining” denied or limited financial services to Black neighborhoods while simultaneously subsidizing White suburbs. Communities of color were cut off from investments that promote affordable housing, good schools, jobs that pay a living wage, and access to clinical care or healthy foods. Poor health exists in places segregated from opportunity. Residential segregation of Blacks and Whites is considered to be a fundamental cause of health disparities in the U.S.

Key Findings

  • In smaller metro or large urban counties, Black residents face greater barriers to health and opportunity than White residents. Black children, youth, and adults have higher rates of child poverty, low birthweight, and infant mortality, and lower high school graduation rates and median household incomes than White residents.
  • Black residents are more affected by levels of segregation than White residents. For example, Black children and youth in more segregated counties fare worse in rates of child poverty and high school graduation than those in less segregated counties. White residents do not.
  • Data suggest that patterns of segregation and limited opportunity for health also hold true for other racial groups. For example, compared to less segregated places, rates of child poverty in more segregated counties are higher for Black, American Indian/Alaskan Native, Hispanic, and Asian children but not for White children.

Residential Segregation and Gaps in Health and Opportunity

A CALL TO ACTION

Addressing Neighborhood Opportunity

A range of policies, programs, and systems changes are needed to ensure opportunities for good health exist in all neighborhoods. There is an array of evidence-informed approaches shown to promote inclusive and connected environments, and expand opportunities for health for all. These include:

  • Ensure access to safe and affordable housing in mixed-income neighborhoods through inclusionary zoning, taxes to advance affordable housing development, and vouchers for low-income households.
  • Support community development and revitalization in ways that avoid displacement of neighborhood residents through policies and incentives to increase economic opportunities, such as jobs that pay a living wage, public transportation systems, and integrated public services.
  • Build social connectedness, cultivate empowered communities, and promote civic engagement by addressing barriers to participation in policymaking, information sharing, and collaboration in neighborhoods, schools, and workplaces.

For information on these and other specific strategies that have been proven to work, visit What Works for Health.

TAKING ACTION

In Kansas City, MO, Driving Community Change to Close the Gap in Life Expectancy

A decade ago, public health officials identified an eight-year gap in life expectancy between the city’s White and Black populations. Segregation and discrimination over the past century fueled this disparity, but community residents and city leaders joined forces to tackle tough conversations on race, stem the violence, increase educational opportunities, improve access to care, and ensure economic justice. Today, the disparity in life expectancy has been reduced to 6.9 years. Learn more at rwjf.org/prize.

Investing in Children and Youth for Our Nation’s Future

Children in Poverty

Poverty limits opportunities and increases the chances of poor health. Children living in poverty are less likely to have access to well-resourced and quality schools, and have fewer chances to prepare for living wage jobs leading to upward economic mobility and good health. Children in poverty is an upstream measure that assesses both current and future health risk. Recent data on poverty show that rates among children and youth are at least 1.5 times higher than rates among adults aged 18 and older – and the rates are even higher for American Indian/Alaskan Native, Black, and Hispanic children and youth. Available data show that for the majority of U.S. counties, child poverty rates for American Indian/Alaskan Native, Black, or Hispanic children are higher than rates for White children, and these rates are often twice as high. This is an urgent problem because the fastest growing population is children and youth of color. A healthy beginning is essential to a healthy future for our children and our nation.

Key Findings

  • Child poverty rates are highest in counties in the Southwest and Southeast regions, as well as parts of Appalachia, the Mississippi Delta, and the Plains.
  • Rural counties continue to have the highest child poverty rates (23.2%), followed by large urban metro (21.2%), smaller metro (20.5%), and suburban counties (14.5%).
  • In the wake of the Great Recession, rates of children in poverty stayed high through 2012 and, despite declines in recent years, remain higher than the pre-recession era. As seen in the map, patterns of recovery vary by place and by race. In general, child poverty rates have not bounced back in many rural counties or those with a greater share of people of color.
  • Child poverty rates for Black and Hispanic children are worse across all types of counties, and are even higher in suburban counties than for White children in rural counties.

Children in Poverty Among U.S. Counties, 2016

Percent Change in Child Poverty, 2012 To 2016

Disparities in Child Poverty by Race/Ethnicity and Place

Teen Births

There are strong ties between poverty and giving birth in teen years. Teenage motherhood is more likely to occur in communities with fewer opportunities for education or jobs. Teen mothers are less likely to complete high school and face challenges to upward economic mobility. In turn, their children often have fewer social and economic supports and fare worse in educational achievement and health outcomes, continuing the cycle of disadvantage. Breaking this cycle requires policies and programs to address gaps in opportunity for youth. Communities with safe and affordable housing in neighborhoods where jobs, good schools, and quality clinical care are accessible also happen to be those with lower teen birth rates and children in poverty.

Key Findings

  • Teen birth rates have been declining across community types and racial groups for more than a decade. Racial gaps have narrowed. Hispanic teens have seen the most improvement with rates falling from 77.7 to 31.9 births per 1,000 females, ages 15-19. Black and American Indian/Alaskan Native teens have also seen notable improvements.
  • Teen birth rates are highest among counties in the Southwest and Southeast, as well as parts of Appalachia, the Mississippi Delta, and the Plains regions. These areas have seen little change over the last decade, while the East and West Coasts have seen improvements.
  • Teens in rural counties have the highest birth rates (35.9 per 1,000), and have also seen the least improvement. Teen birth rates in rural counties are nearly twice the rates in suburban counties (18.5 per 1,000).
  • American Indian/Alaskan Native (34.3 per 1,000), Hispanic (31.9 per 1,000), and Black (28.1 per 1,000) teens consistently have birth rates twice as high as White or Asian teens.

Trends in Teen Birth Rates Among Racial/Ethnic Groups, 2006 To 2016

Teen Birth Rate Among U.S. Counties, 2010-2016

Percent Change in Teen Birth Rate over a Decade*

TAKING ACTION

In Spartanburg County, an Informed Approach to Teen Pregnancy

Community leaders in Spartanburg County, SC took a good, hard look at their data in 2008, and discovered they had a teen birth rate higher than the state average. Deciding to face this issue head on, they brought together teens, providers, parents, and partners to create solutions: a warm welcoming teen health center, accessible and respectful reproductive health care, evidence-based interventions in schools and community settings, and a focus on positive youth development activities. Recent data show improvements: rates have receded by 50% from 2010 to 2016 for all 15-19 year olds. While disparities in teen births among racial groups in South Carolina continue, the gap has closed for teen births among Black and White females in Spartanburg County (in 2016, 23.3 per 1,000 and 23.9 per 1,000, respectively). Learn more at rwjf.org/prize.

A CALL TO ACTION

Solutions for Healthier Children and Youth

No child should have to grow up in poverty, and all children and youth should have the chance for a healthy start to life. Communities can take action to help children and youth gain a foothold on the economic ladder and prepare them to become our future leaders, including:

  • Invest in education from early childhood through adulthood – such as universal pre-kindergarten or career and technical education – to boost employment and career prospects.
  • Increase or supplement income and support asset development in low-income households through expanded earned income tax credits, paid leave, or unemployment insurance.
  • Ensure that everyone has adequate, affordable health care coverage and receives culturally competent services and care by integrating social and behavioral services, increasing accessibility through community health workers and school-based health centers, and training health care professionals on cultural diversity.
  • Foster social connections within communities, and cultivate empowered and civically engaged youth through leadership development and peer mentoring.

To learn more about these and other evidence-informed strategies that can make a difference, visit What Works for Health.

Credits

Recommended citation

University of Wisconsin Population Health Institute. County Health Rankings Key Findings 2018.

Lead Authors

Marjory Givens, PhD, MSPH
Keith Gennuso, PhD
Amanda Jovaag, MS
Julie Willems Van Dijk, PhD, RN, FAAN

This publication would not have been possible without the following contributions:

Research Assistance

Courtney Blomme, RD
Elizabeth Pollock, PhD
Joanna Reale
Jennifer Robinson
Matthew Rodock, MPH
Anne Roubal, PhD

Alison Bergum, MPA
Kiersten Frobom
Lael Grigg, MPA
Bomi Kim Hirsch, PhD
Jessica Rubenstein, MPA, MPH
Jessica Solcz, MPH

Outreach Assistance

Kate Kingery, MPA
Kitty Jerome, MA
Kate Konkle, MPH
Raquel Bournhonesque, MPH
Ericka Burroughs-Girardi, MA, MPH
Janna West Kowalski, MS
Aliana Havrilla, MPIA
Antonia Lewis, MPH
Karen Odegaard, MPH
Justin Rivas, MPH, MIPA
Attica Scott, MS
Jerry Spegman, JD

Astra Iheukumere, MPA, MBA

Carrie Carroll, MPA
Olivia Little, PhD
Devarati Syam, PhD

Communications and Website Development

Burness
Forum One

Kim Linsenmayer, MPA
Matthew Call
Komal Dasani, MPH
Lindsay Garber, MPA
Samuel Hicok
James Lloyd, MS

Data

Centers for Disease Control and Prevention: National Center for Health Statistics
Dartmouth Institute for Health Policy & Clinical Practice
Measure of America

Robert Wood Johnson Foundation

Abbey Cofsky, MPH
Jessica Mark, MPH
Joe Marx
Donald Schwarz, MD, MPH
Kathryn Wehr, MPH
Renee Woodside

Scientific Advisory Group

Pat Remington, MD, MPH (Chair)
Renee Branch Canady, PhD, MPA
Jim Chase, MHA
Maggie Super Church, MSc, MCP
Tom Eckstein, MBA
Rebecca Tave Gluskin, PhD
Kurt Greenlund, PhD
James Holt, PhD, MPA
Carolyn Miller, MA, MS
Ana Diez Roux, MD, PhD
Steven Teutsch, MD, MPH
Trissa Torres, MD, MSPH, FACPM