Key Findings
The data reveal substantial shortfalls in America’s health potential at the national level and in every
state. The findings presented here provide new state-by-state evidence of the extent of unrealized
health potential among children in the United States.
Infant Mortality
• In the United States overall during 2000-2002, more than six of every 1,000 babies born alive
each year died before reaching their first birthdays. Overall infant mortality rates in states varied
considerably, from 4.6 deaths per 1,000 live births in Massachusetts to 11.0 deaths per 1,000 live
births in Washington, D.C.
• Nationally, and in nearly every state, infant mortality rates increased with decreasing levels of
mothers’ education. Compared with babies born to the most-educated mothers (those with at least
16 years of schooling), infant mortality rates were higher—by as much as 12 deaths per 1,000 live
births—for babies born to the least-educated mothers (those with less than 12 years of completed
schooling). With few exceptions, infant mortality rates also were higher—by up to five deaths per
1,000 live births—among babies born to mothers in the second highest education group (those with
13-15 years of completed schooling).
• While gaps in infant mortality by mothers’ education were evident in every state, the difference
between the overall infant mortality rate and the rate for babies born to the most-educated mothers
varied from less than one (in Maine) to over seven (in Washington, D.C.) deaths per 1,000 live births.
• Even among babies born to the most-educated mothers, infant mortality rates in nearly every
state exceeded the national benchmark—3.2 infant deaths per 1,000 live births—which should
be attainable.
Children’s General Health Status
• In the United States during 2003, 15.9 percent of children ages 17 years or younger had less than
optimal (neither very good nor excellent) health. The percent of children with less than optimal
health varied across states from 6.9 percent in Vermont to 22.8 percent in Texas.
• Nationally, and in every state, the percent of children with less than optimal health varied with family
income. Compared with higher-income children (in families with incomes at or above 400% of the
Federal Poverty Level), children in poor families (below 100% of the Federal Poverty Level) were
more likely—over six times as likely, in some states—to be in less than optimal health. Differences
were not confined to comparisons between the top and bottom groups. With few exceptions,
children in middle-income families (200-399% of the Federal Poverty Level) also appear more
likely—over twice as likely, in some states—than children in higher-income families to be in less
than optimal health.
• While the gap in children’s general health status by income was evident in every state, the size of
the difference between the overall percent of children in less than optimal health and the percent
among children in higher-income families varied across states—from a difference of 2 percent in
New Hampshire to 16 percent in Texas.
• Even among children in higher-income families, the percent of children with less than optimal health
in almost every state exceeded the national benchmark—3.5 percent—which should be attainable.
Unrealized health potential is the difference between
‘what is’ (the current level of children’s health) and
‘what is attainable’ (the level of health that would occur
if all children were as healthy as children in the most
socially-advantaged group).
Introduction
Children’s health is the foundation for health throughout life, and measures of child health are
important indicators of our nation’s overall state of health. This chartbook focuses on the health of
children to explore whether we are reaching our full health potential as a nation and in every state.
Considering the differences between ‘what is’ (current overall levels of child health) and ‘what is
attainable’ (the levels of health that would be achieved if all children were as healthy as children in
the most favorable social and economic conditions), the new state-by-state evidence presented
here reveals substantial unrealized health potential among America’s children.
Purpose
This chartbook is intended to inform, raise awareness and stimulate discussion. Its purpose is
to provide information that will be helpful to policy-makers, advocates and other leaders in their
efforts to: (1) assess how far they are from reaching the full health potential of children in their state;
(2) raise awareness about the need to address social factors in order to close the current gaps
in children’s health; and (3) stimulate discussion and debate within states and nationally about
promising directions for closing those gaps.
While analyzing the causes of the health gaps was not within the scope of this Commission’s work,
a large body of research shows that the causes are complex, and that medical care interventions
are important but not sufficient. The information presented should be used as a point of departure
for a process of inquiry—stimulating an exploration of the most promising national and state
policies to realize America’s full health potential by shaping healthier conditions in which children
and their families live, work, learn and play.
This report was produced by research staff of the Robert Wood Johnson Foundation Commission
to Build a Healthier America to aid Commissioners as they explore actions outside the medical
care system that could improve the health of all Americans. Additional information about the
Commission is available at www.commissiononhealth.org.
Content
Findings from America’s Health Starts with Healthy Children: How Do States Compare? are
presented in two forms: a print overview and a Web version that contains a wealth of state-by-state
data. The print version includes three sets of charts. The first set describes how two key indicators
of children’s health vary markedly at the national level by social and economic factors. The second
set of tables and maps describes differences in these indicators by social and economic factors
at the state level, and states are ranked according to the size of the unrealized health potential in
children’s health. The final set of charts provides an example of the information that is available on
the Commission Web site for every state.
Readers can download individual files for each state at www.commissiononhealth.org/statedata.
The files provide data on infant mortality and children’s general health status, as well as information
on how social factors such as a family’s income, parents’ education levels and racial or ethnic
group are linked with infant mortality and children’s general health status in the state.
6 RWJF Commission to Build a Healthier America
Children’s Health Is an Indicator
of Our Nation’s Health
Children’s Health Shapes Health roughout Life
Good health and a nurturing and stimulating environment during childhood determine our potential
for health and well-being throughout life. Getting a healthy start in life improves a child’s chances
of becoming a healthy adult and avoiding chronic conditions that can be limiting or disabling.
Childhood obesity, for example, is a strong predictor of adult obesity, with the accompanying risks
of chronic disease, disability and shortened life expectancy. In addition to children’s health, child
development also shapes adult health in powerful ways. A large body of research has consistently
shown that cognitive and behavioral development early in life are strongly linked to an array of
important health outcomes later in life. Adult health outcomes that have been linked to early child
development (often through effects of educational attainment and/or health-related behaviors, and
also through more direct physiologic effects) include heart disease and stroke, high blood pressure,
diabetes, obesity, smoking, drug use and depression. These conditions account for a major portion
of preventable illness and premature death in the United States.
What Shapes Children’s Health?
A child’s health is powerfully shaped by the environment in which he or she lives, learns and plays.
Both family and community matter and private and public policies at the local, state and national
level influence a child’s opportunity to be healthy. This chartbook highlights three of many social
factors that are known to be strongly related to children’s health: levels of household income,
educational attainment in the family, and racial or ethnic group. Many—although not all—modifiable
factors known to influence children’s health are shaped in significant ways by family income and/
or education. For example, educated parents may have a better understanding of health-related
behaviors, along with resources to make healthier choices. They may be better able to obtain well-
paying jobs, which in turn can determine income and access to health insurance. Income is often
linked with housing quality and neighborhood of residence, as well as being able to afford a healthy
diet. In addition to family characteristics, community influences such as safety, school quality,
presence of favorable role models and availability of healthful foods and recreational opportunities
also affect children’s health. Racial or ethnic group matters in part because it continues to influence
educational and employment opportunities; in addition, discrimination and its legacy in residential
segregation mean that black and Hispanic families more often live in substandard housing
and unsafe or deteriorating neighborhood conditions compared with whites with similar incomes
and education.
Medical care is important for children’s health. For example, timely immunizations and regular
treatment for conditions like asthma can make a big difference in overall well-being. Genetic
predisposition to certain diseases also influences children’s health. But many experts have
concluded that medical care and genes actually play a relatively minor role compared with the
influence of the physical and social conditions in which children grow up. Children continue to
develop not only physically but also cognitively and behaviorally through adolescence, but the first
five years of life are particularly crucial.
7 America’s Health Starts With Healthy Children
Healthier behaviors
by parents
Positive effects on
neuroendocrine
systems that can
lead to lesser risks
for developing
chronic diseases
such as heart disease
and diabetes
Resources to cope
with stressors
(e.g., child care,
transportation,
health insurance)
Decreased levels
of chronic stress
experienced
by children
Increased family
income
Better jobs and
increased family
income
Affordability of
good housing,
a safe neighborhood
with access
to recreational
opportunities and
nutritious diet
Higher levels
of parents’
education
Good role models for
children and lower
exposure to unhealthy
conditions such as
secondhand smoke
Higher levels
of parents’
education
How Social Environments in Childhood
Can Shape Health Later in Life
8 RWJF Commission to Build a Healthier America
What Do We Know About Ways to Improve Children’s Health?
Although there is much more to learn about how to improve children’s health, significant new
knowledge developed over the past 15 years points us in promising directions. We now know that
several modifiable factors can make a dramatic difference in children’s health and well-being. Not
surprisingly, the greatest improvement can generally be seen among those who start off farthest
behind as a result of living in disadvantaged circumstances. We have learned, however, that
potential improvements in health are not limited to children in poor and less-educated families; even
children in families considered to be “middle class”—in other words, the majority of children in this
country—can achieve improved health with timely interventions in the following areas:
• Adequate stimulation and interaction with supportive caregivers, including family, teachers and
child-care workers.
• A nutritious diet and sufficient physical activity.
• Safe and health-promoting neighborhood conditions, with access to grocery stores, sidewalks and
parks and recreational areas.
Improving children’s social and physical environments—which are clearly linked with household
income and education—enhances their health and cognitive, behavioral and physical
development.
Improving children’s health and cognitive, behavioral and physical development gives them the
foundation needed to be healthy as adults.
For more information see Issue Brief 1: Early Childhood Experiences: Laying the Foundation for
Health Across a Lifetime at www.commissiononhealth.org.
A child’s health is powerfully
shaped by the environment
in which he or she lives,
learns and plays. Both family
and community matter.
9 America’s Health Starts With Healthy Children
Measures of Child Health
• Infant mortality. Deaths during the first year of life were considered a key indicator of population
health. Infant mortality rates—the number of infant deaths per 1,000 live births—were examined at
the national and state levels for babies born to women ages 20 years or older; this age restriction
permitted us to more completely examine differences in infant mortality by mother’s education.
Infant mortality rates were considered to be statistically reliable for groups with at least 20
infant deaths.
• Children’s general health status. A parent’s or guardian’s overall assessment of a child’s health (as
excellent, very good, good, fair or poor), which studies show corresponds closely with objective
clinical assessments by health professionals. The focus at the national and state levels was on the
percentage of children ages 17 years or younger whose general health status was considered to be
less than optimal—that is, assessed by their parents or guardians to be other than excellent or very
good. Rates of less than optimal health were considered to be statistically reliable when the relative
standard errors were 30 percent or less.
Social Factors
• Income. Taking family size into account, family income was categorized in 100-200 percent
increments of the Federal Poverty Level (FPL), which has been defined as the amount of income
providing a bare minimum of food, clothing, transportation, shelter and other necessities. In 2006,
the U.S. FPL was $16,079 for a family of three and $20,614 for a family of four. Children were
considered to be poor (with household incomes below 100% of FPL), near poor (100-199% of
FPL), middle income (200-399% of FPL), or higher income (400% of FPL or higher).
• Education. Slightly different measures were used to describe education, depending on the indicator
of children’s health and data source. To examine infant mortality in relation to social factors, the
educational attainment of the mother was measured in years of schooling and categorized to
correspond to level of education (0–11 years, 12 years, 13–15 years, and 16 or more years). To
describe social factors at the national and state levels and to examine children’s general health
status by those factors, education was categorized according to the highest level attained by any
person in the household. Social factors were examined using four categories (less than high-school
graduate, high-school graduate, some college and college graduate); children’s general health
status was examined using three categories (less than high-school graduate, high-school graduate
and at least some college).
• Racial or ethnic group. Mother’s (when examining infant mortality) and child’s (when examining
children’s general health status) racial or ethnic group were considered using slightly different
categories depending on the data source and size of the groups. At the national level, we
considered: (a) all categories for which information was collected by the U.S. Census Bureau, to
describe the racial or ethnic composition of all children; and (b) three categories—non-Hispanic
whites, non-Hispanic blacks and Hispanics, to describe differences in the children’s health
indicators by racial or ethnic group. At the state level, we considered: (a) all categories for which
information in the state was collected by the National Survey of Children’s Health, to describe
the racial or ethnic composition of all children; and (b) categories in the relevant data source that
included at least 3 percent of children in the state (smaller groups and individuals reporting more
than one racial or ethnic group were included with “other”), to describe differences in the children’s
health indicators.
10 RWJF Commission to Build a Healthier America
Data Sources
Four sources of data were used to produce this chartbook:
• The 2006 American Community Survey (ACS), conducted by the U.S. Census Bureau, was
analyzed to obtain information, nationally and in each state, on household income and racial or
ethnic group.
• The 2005-2007 Current Population Survey (CPS), conducted by the U.S. Census Bureau, was
analyzed to obtain information, nationally and in each state, on household education levels.
• The 2000-2002 Period Linked Birth/Infant Death Data Set from the Centers for Disease Control
and Prevention, National Center for Health Statistics, was used to obtain information on infant
mortality, nationally and in each state, by mother’s educational attainment and mother’s racial
or ethnic group.
• The 2003 National Survey of Children’s Health (NSCH), conducted by the Centers for Disease
Control and Prevention, National Center for Health Statistics, was analyzed to obtain information
on: children’s general health status, nationally and in each state, by household income and
education and by child’s racial or ethnic group; children’s general health status by income within
racial or ethnic groups nationally; and children’s general health status according to health-related
behaviors of persons in their families, within each household income group nationally.
A full list of data sources, including complete descriptions and limitations of sources, can be found
in the Technical Notes available at www.commissiononhealth.org/PDF/ChartbookTechNotes.pdf.
Analyses
We examined differences in each of the two measures of children’s health by social groups at both
the national and state levels. Infant mortality was examined, by mother’s education and by mother’s
racial or ethnic group, at the national level and within each state; information on income was not
included in the data source. Children’s general health status was examined, by household income
and level of education and by child’s racial or ethnic group, at the national level and within each
state; in addition, we examined differences at the national level in this health measure by income
within racial or ethnic groups and by household health-related behaviors within income groups.
We estimated the size of the “health gaps” for each state and Washington, D.C., using a standard
measure known as the Population Attributable Risk, or PAR. In this report, the PAR was calculated
at the state level to quantify the improvement in overall infant mortality or children’s general health
status that would occur if all infants or children in the state had the level of health experienced by
those in the state’s most socially-advantaged group. States were ranked according to the size of
this health gap; states with the same size gap (to one decimal point) were given the same ranking.
For mapping purposes, states were grouped based on the size of the gaps into three approximately
equal groups (i.e., as having small, medium or large gaps).
11 America’s Health Starts With Healthy Children
It is important to note that the highest education and income groups used here to reflect the
most socially-advantaged groups were relatively large: Nationally, 35 percent of children lived in
households with at least one adult who had graduated from college and 28 percent lived in families
with incomes at or above four times the FPL. If the data sources had permitted comparisons with
children in the top 5 or 10 percent of family education and income levels, the health differences
could have been even larger. The health gaps reported here thus are likely to understate the true
magnitude and extent of unrealized health potential in each state and in the nation overall.
A “national benchmark” was also calculated for each measure of children’s health. This additional
reference point—intended to represent a level of good health that should be attainable for all
children in every state—is featured to emphasize two additional points:
(1) Levels of health among children are better in some states than in others, even when only
children in the highest income or education groups are considered.
(2) Differences in health occur among children even within the most socially-advantaged groups.
At every level of family income or education, children’s opportunities for good health are also
shaped by other factors, including whether the adults they live with practice good health-related
habits like exercising regularly.
For infant mortality, the national benchmark used here—3.2 deaths per 1,000 live births, found
in New Jersey and Washington state—was the lowest statistically-reliable infant mortality rate in
any state for babies born to the most-educated mothers. (Information on health-related behaviors
was not available in the infant mortality data source.) For children’s general health status, the
national benchmark—3.5 percent of children in less than very good health, found in Colorado—was
selected as the lowest statistically-reliable rate in any state of less than optimal health among
children in higher-income households where adults practiced healthy behaviors (i.e., non-smokers
and at least one person who exercised regularly).
For further information on analytic methods, see the Technical Notes for this document at
www.commissiononhealth.org/PDF/ChartbookTechNotes.pdf.
Charts and Data
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