America's 50 Healthiest Counties for Kids, a new set of rankings by U.S. News, highlights counties that feature, among other child-friendly data, fewer infant deaths, fewer low-birth-weight babies, fewer deaths from injuries, fewer teen births and fewer children in poverty.
Experts say the analysis, released as part of U.S. News Best Children's Hospitals 2013-2014, represents the first national, county-level assessment of how health and environmental factors affect the well-being of children younger than 18. Perhaps the most striking finding is that what it takes to make a county healthy for kids can't be reduced to one or two numbers. As shown in the table below, even the highest-ranking counties grapple with such challenges as large numbers of children in poverty and high teen birth rates. Top-ranked Marin County, a northern suburb of San Francisco, struggles with rates of teen births and children in poverty almost twice as high as 5th-ranked metro Milwaukee's Ozaukee County.
|Healthiest Counties for Kids|
|Rank||County||Score (0-100)||Low Birthweight (under 5.5 lbs)||Infant Death Rate
|Teen Birth Rate
|Children in Poverty||Injury Death Rate
|1||Marin County, Calif.||100.0||6.3%||319.2||13.6||10.8%||8.7|
|2||San Francisco County, Calif.||94.0||7.0%||446.6||16.9||16.0%||13.0|
|3||Chittenden County, Vt.||93.6||6.7%||337.6||10.9||10.7%||7.9|
|4||Norfolk County, Mass.||93.4||7.2%||354.4||7.1||6.7%||8.8|
|5||Ozaukee County, Wis.||91.8||5.4%||372.3||7.3||6.0%||14.5|
|6||Middlesex County, Mass.||90.8||7.5%||426.8||12.2||9.3%||6.5|
|7||Boulder County, Colo.||90.7||7.7%||571.0||18.2||13.0%||10.3|
|8||Douglas County, Colo.||90.5||8.9%||401.7||10.5||4.9%||10.3|
|9||Montgomery County, Md.||90.1||8.1%||563.8||20.6||8.8%||9.9|
|9||San Mateo County, Calif.||90.1||6.7%||385.3||22.4||10.0%||10.0|
|11||Placer County, Calif.||89.6||5.7%||399.2||16.5||9.9%||10.2|
|12||Johnson County, Iowa||88.5||6.6%||554.2||11.4||15.9%||11.8|
|13||Hunterdon County, N.J.||87.9||6.7%||267.0||4.3||4.5%||8.5|
|14||Bergen County, N.J.||87.6||7.7%||337.0||5.6||8.2%||7.3|
|14||Hampshire County, Mass.||87.6||6.7%||425.2||6.8||12.3%||5.8|
|16||Waukesha County, Wis.||87.5||6.4%||546.0||10.2||6.6%||10.1|
|16||Westchester County, N.Y.||87.5||8.4%||524.9||13.6||6.8%||17.7|
|18||Nassau County, N.Y.||87.4||8.0%||504.6||8.6||9.3%||11.8|
|19||Santa Clara County, Calif.||87.3||6.7%||376.3||8.0||12.6%||25.7|
|20||DuPage County, Ill.||87.2||7.2%||612.6||8.0||11.0%||15.8|
|21||Dane County, Wis.||86.7||6.2%||507.3||10.8||14.5%||18.7|
|22||Cass County, N.D.||86.4||6.5%||589.3||7.9||12.1%||18.7|
|23||Olmsted County, Minn.||86.1||6.4%||663.9||12.4||10.8%||25.1|
|24||Morris County, N.J.||85.5||7.5%||367.8||6.9||5.5%||6.8|
|24||Yolo County, Calif.||85.5||5.3%||393.2||20.2||20.5%||13.0|
|26||Howard County, Md.||85.4||7.8%||517.3||12.8||7.5%||12.0|
|27||Johnson County, Kan.||85.2||6.3%||621.5||19.3||8.4%||11.8|
|28||Fairfax County, Va.||85.1||6.9%||515.4||16.5||9.0%||8.7|
|28||La Crosse County, Wis.||85.1||6.0%||461.1||17.5||15.4%||14.9|
|28||Somerset County, N.J.||85.1||8.0%||281.7||12.0||6.2%||8.4|
|31||Santa Cruz County, Calif.||84.8||5.8%||404.5||27.2||18.5%||11.3|
|32||King County, Wash.||84.3||6.6%||420.3||19.8||14.5%||11.8|
|33||Washington County, Minn.||84.0||6.1%||505.6||14.4||7.1%||11.2|
|34||Grand Forks County, N.D.||83.9||6.5%||418.6||20.9||14.6%||14.5|
|35||Montgomery County, Pa.||83.4||7.2%||526.8||14.9||7.2%||9.6|
|36||Orange County, Calif.||83.2||6.4%||474.7||28.0||17.9%||10.2|
|37||Alameda County, Calif.||83.1||7.1%||469.8||26.6||16.8%||16.1|
|38||Delaware County, Ohio||83.0||7.2%||383.8||15.1||5.8%||7.3|
|38||Grafton County, N.H.||83.0||6.4%||530.6||14.5||14.3%||9.9|
|38||New York County, N.Y.||83.0||8.7%||458.2||26.1||26.7%||7.6|
|41||Dakota County, Minn.||82.8||6.2%||350.2||18.6||9.2%||8.1|
|42||Cumberland County, Maine||82.5||6.6%||618.9||16.0||15.1%||13.2|
|43||Fairfield County, Conn.||82.3||7.6%||504.2||18.9||12.4%||9.2|
|44||Carver County, Minn.||82.0||5.7%||443.9||11.3||6.2%||12.3|
|45||Gallatin County, Mont.||81.7||6.5%||629.1||16.4||13.1%||10.5|
|45||San Luis Obispo County, Calif.||81.7||6.0%||383.0||19.1||17.5%||16.5|
|47||Monmouth County, N.J.||81.5||7.6%||417.9||14.4||9.3%||10.9|
|48||Larimer County, Colo.||81.3||7.8%||475.7||21.3||14.0%||10.9|
|49||Sonoma County, Calif.||81.0||5.8%||435.8||25.4||15.9%||9.6|
|50||Williamson County, Tenn.||80.9||6.9%||263.9||13.0||7.3%||8.4|
James Perrin, president-elect of the American Academy of Pediatrics, says the new analysis offers a "really useful" tool for assessing the health status of children in communities across the U.S. "If I'm a mayor of a small town in Iowa, this analysis gives me a guide to what we should be thinking about," says Perrin, a professor of pediatrics at Harvard Medical School.
The rankings were developed with the help of the University of Wisconsin Population Health Institute, which evaluates health data for the U.S. population as part of its County Health Rankings and Roadmaps program, a collaboration with the Robert Wood Johnson Foundation. Besides the data displayed here, the percentage of uninsured children, air quality (except for Alaska and Hawaii); rates of adult smoking and adult obesity, and access to physicians and parks also were considered. All of the variables were equally weighted.
[View map of the 50 healthiest counties for kids.]
Other than Williamson County, Tenn., a relatively high-income community in metro Nashville that ranked No. 50 on the list, no high-ranking county is in the South. The other 49 ranked counties are fairly evenly distributed around the country — with clusters in the Northeast and California — and vary in population size, from about 66,000 in Grand Forks County, N.D., to more than 3 million in Orange County, a Los Angeles suburb. All of the top-ranked counties had lower percentages of low-birth-weight babies and lower rates of infant deaths and teen pregnancies than the U.S. median. Access to primary care physicians, however, ranged widely even within a single state. For instance, in Olmstead County, Minn., home of the Mayo Clinic, there is one physician for every 420 people, compared with just one for every 1,495 in Dakota County, just a few counties to the north. Even in the top-ranking counties, such variations were the rule rather than the exception.
Some of the variables that went into the rankings, such as low birth weight, infant mortality and teen pregnancy, directly relate to health outcomes. Others, such as access to primary care physicians, air quality and parks, are more indirect. "Everybody lives in an environment that helps them to be healthy or is detrimental to health," says the University of Wisconsin's Bridget Catlin, director of the county health rankings program. "It starts with a mother's health, her health behaviors during pregnancy, the care she gets during pregnancy and what environment a child lives in after birth. A parent can't feed a child healthy food if there's no healthy food to be found." And Perrin observes that "communities where it's not safe to be outside, where there aren't good parks, are really not good for kids."
About 1,200 of the nation's 3,143 counties (a total that takes in county equivalents such as Louisiana's parishes) were evaluated for the rankings. Many states don't collect county-level information on residents' health, whereas populous states, such as California, Florida and New York, tend to gather and report more data. In some counties, the population is so small that the numbers are unreliable, or the few events fall below state or federal reporting thresholds. And because states don't collect county-level information on childhood smoking and obesity, the rankings incorporated percentages for adults. Catlin says this is justified because more adult smokers mean more children are exposed to secondhand smoke, a demonstrated health risk. Studies have also shown a moderately strong correlation between adult and childhood obesity, she says.
The experts who study community health yearn for more and better data. "We don't have county-level data on kids with diabetes, controlled or uncontrolled, or on childhood obesity rates," says Ali Mokdad of the Institute for Health Metrics and Evaluation at the University of Washington. "Almost every kid in this country goes to school. We could measure height and weight, but nobody's connecting the dots."
Perhaps the most tragic statistic is the rate at which children die from injuries of all kinds; it is more than three times higher in counties in the bottom 10 percent of all of those evaluated than those at the top. "How can this be happening in a country like ours, with our resources?" says Mokdad.