Health Determinants

Behaviors

Four measures reflect behaviors that are potentially modifiable through a combination of personal, community and clinical interventions: smoking, obesity, binge drinking and high school graduation. These items are determinants that measure behaviors and activities having an immediate or delayed effect on health and are prominently included in these rankings.

However, the selection of these four does not imply that they are the only underlying behaviors that need to be addressed in a comprehensive public health effort. For example, the American Academy of Family Physicians suggests that to improve health, individuals should:

• Avoid any form of tobacco
• Eat a healthy diet
• Exercise regularly
• Drink alcohol in moderation, if at all
• Avoid use of illegal drugs
• Practice safe sex
• Use seat belts (and car seats for children) when riding in a car or truck
• Avoid sunbathing and tanning booths
• Keep immunizations up-to-date
• See a doctor regularly for preventive care

Additional suggestions for individual initiatives are in Healthy People 2020, published by the U.S. Department of Health and Human Services, Washington, D.C.

The impact of changing behaviors is huge. CDC estimates that if tobacco use, poor diet and physical inactivity were eliminated, 80 percent of heart disease and stroke, 80 percent of Type 2 diabetes and 40 percent of cancer would be prevented.¹ Smoking and secondhand smoke are estimated to cause 443,000 deaths annually.  Further, it is estimated that 25 million Americans who are alive today will die prematurely from smoking-related illnesses.²

Smoking measures the percent of the population over age 18 who smoke tobacco products regularly. It is defined as the percentage of adults who self-report smoking at least 100 cigarettes and currently smoke regularly. The 2011 ranks are based on self-report data from CDC’s 2010 Behavioral Risk Factor Surveillance System (BRFSS).  

The prevalence of smoking in the population has an adverse impact on overall health by causing increased cases of respiratory diseases, heart disease, stroke, cancer, preterm birth, low birth weight and premature death (http://www.cdc.gov/tobacco/). Tobacco use is estimated to be responsible for about one in five deaths annually, or about 443,000 deaths per year³ . It is a lifestyle behavior that an individual can directly influence with support from the community and, as required, clinical intervention. It is an indication of known, addictive, health-adverse behavior within the population.

The national average is 17.3 percent of adults, down 0.6 percent from last year. The proportion of the population who smokes varies from a low of 9.1 percent in Utah to more than 26.8 percent in West Virginia. Due to the limits of the BRFSS, caution must be used in comparing changes in prevalence of smoking in states with small populations.

 

Top Improvements in Smoking (Percent of population who have stopped smoking)

Last Year		Since 2006 Edition		Since 2001 Edition		Since 1990 Edition
State	Change	State	Change	State	Change	State	Change
Oregon	2.8 %	Arizona	6.7%	New Hampshire	8.4%	Rhode Island	18.7%
Arizona	2.6%	Tennessee	6.6%	Nevada and Rhode Island (tie)	7.7%	Connecticut	16.4%
New York	2.5%	Indiana	6.1%	Iowa	7.1%	Arizona	16.0%
Connecticut	2.2%	Pennsylvania	5.2%	Connecticut	6.7%	Vermont	15.3%
South Dakota and Texas (tie)	2.1%	Minnesota	5.1%	Idaho and New Jersey (tie)	6.6%	Michigan	15.1%

 

Binge Drinking measures the percentage of the population over age 18 that drank excessively in the last 30 days. It is defined as males having five or more drinks and females having four or more drinks on one occasion. The 2011 ranks are based on 2009 and 2010 BRFSS self-report data. Binge Drinking is measured over a two-year span to increase the reliability of estimates and to allow better state-to-state comparisons.
 
Binge drinking has an adverse effect on health due to the impact of excessive alcohol on increased motor vehicle injuries and deaths, increased aggression, unintentional injury, fetal damage and liver diseases along with other health risks (http://www.cdc.gov/alcohol/). It is a proxy indicator for excessive drug and alcohol use within a population.

The prevalence of binge drinking varies from less than 10 percent in Tennessee, Utah and West Virginia to more than 20 percent in North Dakota and Wisconsin. The national average is 15.5 percent of adults who binge drink and has varied from 14.3 percent to 16.4 percent of adults over the last 14 years.

Obesity is the percentage of the adult population estimated to be obese, defined as having a body mass index (BMI) of 30.0 or higher. BMI, as defined by CDC, is equal to your weight in pounds divided by your height in inches squared and then multiplied by 703. CDC has a calculator for BMI at http://www.cdc.gov/nccdphp/dnpa/bmi/calc-bmi.htm. The 2011 ranks are based on self-reported weight and height from CDC’s 2010 BRFSS data.  

Obesity is known to contribute to a variety of diseases, including heart disease, diabetes, stroke, certain cancers and general poor health (http://www.cdc.gov/nccdphp/dnpa/obesity/). The medical care costs for treating obesity and obesity-related health issues are overwhelming (http://www.cdc.gov/obesity/causes/economics.html). In 2008, it was estimated that $147 billion dollars was spent on obesity-related direct and indirect medical care costs.⁴

In the United States, 27.5 percent of the adult population are obese, up from 26.9 percent of the population in the 2010 Edition, 24.4 percent in the 2006 Edition, 20.0 percent in the 2001 Edition and substantially more than double the rate of 11.6 percent of the population in the 1990 Edition. This means that more than one-in-four are obese in the United States – that is almost 65 million adults with a body mass index of 30.0 or higher. If the population of the United States could return to the weight status of 1990, there would be more than 37 million fewer obese individuals – more than the entire population of the most populous U.S. state, California.

The prevalence of obesity ranges from 21.4 percent of the population in Colorado to over one-third of the population in Alabama and Mississippi. Twenty-one states held or decreased the prevalence of obesity in the last year. Oregon reported the largest increase – an additional four percent of the population is now obese.

Least Increase in Obesity (Percent of population who have changed status)

*A negative number indicates a decrease in obesity rates

 
High School Graduation estimates the percentage of incoming ninth graders who graduate within four years and are considered regular graduates. The National Center for Education Statistics collects enrollment and completion data and estimates the graduation rate for each state. The rate is the number of graduates divided by the estimated count of freshmen four years earlier. This estimated count of freshmen is the sum of the number of 8th graders five years earlier, the number of 9th graders four years earlier and the number of 10th graders three years earlier divided by three. Enrollment counts also include a proportional distribution of students not enrolled in a specific grade. The 2011 ranks are based on 2007 to 2008 school year data.

Education is a vital contributor to health as consumers must be able to learn about, create and maintain a healthy lifestyle, and understand and participate in their options for care.
 
The rate varies from over 89 percent of incoming ninth graders who graduate within four years in Wisconsin and Vermont to less than 60 percent in Nevada. The national average is 74.7 percent, compared to 73.9 percent in the 2010 Edition.

Data are not adjusted for the presence or quality of basic health and consumer health education in the curriculum, for continuing education programs nor for other non-traditional learning programs. Also, individual states are increasingly altering graduation requirements, which may affect their reported number of regular graduates, their graduation rate and the comparability of these rates across time.

 

Top Improvements in High School Graduation (Increase in percentage of ninth graders who graduate within four years)

Community and Environment

Five measures are used to represent the community and the environment: the violent crime rate, the occupational fatalities rate, the percentage of children in poverty, the incidence of infectious disease and exposure to air pollution. Measures of community and environment reflect the reality that the daily conditions in which we live our lives have a great effect on achieving optimal individual health. The presence of pollution, violence, illegal drugs, infectious disease and unsafe workplaces are detrimental. In addition, studies indicate that the general socio-economic conditions and the level of education have a significant relationship to the healthiness of a community’s residents.

These determinants measure both positive and negative aspects of the community and environment of each state and their effects on the population’s health.  Again, there are many additional efforts of communities that improve the overall health of a population but are not directly reflected in these five measures. Each community has its own strengths, challenges and resources and should undertake a careful planning process to determine which action plans are best for them.
 
Violent Crime measures the annual number of murders, rapes, robberies and aggravated assaults per 100,000 population. The 2011 ranks are based on 2010 data (Crime in the United States: 2010. Washington, D.C., Federal Bureau of Investigation).

The violent crime rate measures the effect criminal behavior has on the population’s health, as it reflects an aspect of current U.S. lifestyle and is an indicator of health risk and death. The violent crime rate is dependent upon many factors, not just population; thus when taking action to combat crime, each state must consider its specific circumstances.

The violent crime rate varies from less than 200 offenses per 100,000 population in Maine, Vermont, New Hampshire and Wyoming to more than 600 offenses per 100,000 population in Nevada, Alaska, Delaware and Tennessee. The national average is 404 offenses per 100,000 population, down 25 offenses per 100,000 population from the prior year and down 205 offenses per 100,000 population from the 1990 Edition.  Crime peaked in 1993 and 1994 at 758 offenses per 100,000 population and has since dropped by 53 percent.

Greatest Decreases in Violent Crime (Change in number of offenses per 100,000 population)

Occupational Fatalities measures the combined rate of fatal injuries in the following industries: construction, manufacturing, trade, transportation, utilities, professional, and business services, as defined by the North American Industry Classification System (NAICS). Rather than using an occupational fatality rate for all workers, this industry-adjusted rate is used to account for the different industry mixes in each state in order to accurately reflect the safety differences between the states. Occupational fatalities are measured over a three-year span because of their low incidence rate. In states where occupational fatality data is not available for a specific industry, the national rate for that industry was used to calculate the state’s occupational fatality rate. The 2011 ranks are based on 2008 to preliminary 2010 occupational fatality data (Census of Fatal Occupational Injuries, Bureau of Labor Statistics, U.S. Department of Labor, Washington, D.C.). The industry population data used to calculate rates was based on 2010 data collected from the Bureau of Economic Analysis.  

Occupational fatalities represent the impact of hazardous jobs on the population. Occupational injuries would be a preferred measure; however, there is not a uniform reporting system used by all 50 states.

Scores vary from 2.5 deaths per 100,000 workers in Minnesota and Massachusetts to over 10 deaths per 100,000 workers in Alaska. The national rate is 4.0 deaths per 100,000 workers, down from 4.4 deaths per 100,000 workers in the 2010 Edition.

Children in Poverty measures the percentage of related persons under age 18 living in a household that is below the poverty threshold. The poverty threshold established by the U.S. Census Bureau for a household of four people which includes two children living in the lower 48 states is approximately $22,113 in household income. The 2011 ranks are based on 2010 data (Current Population Survey, 2011 Annual Social and Economic Supplement. Washington, D.C., U.S. Census Bureau).

Children living in poverty are challenged by lack of access to health care, limited availability of healthy foods, constrained choices for physical activity, limited access to appropriate educational opportunities and stressful living conditions.

The percentage of children in poverty ranged from 6 percent of persons under age 18 in New Hampshire to a high of more than 30 percent in Mississippi and Louisiana. The national average is 21.5 percent, an increase from 20.7 percent of children in the 2010 Edition and up 5.7 percent of children from the low of 15.8 percent of persons under age 18 reported in the 2002 Edition. That is a 36 percent increase in childhood poverty in the last ten years and is higher than the 20.6 percent reported in the 1990 Edition.

Greatest Decreases in Children in Poverty (Change in the percentage of children in poverty)

 

Greatest Increases in Children in Poverty (Change in the percentage of children in poverty)

 

Infectious Disease measures the combined incidence of measles, pertussis, Hepatitis A and syphilis per 100,000 population. Two-year averages are used to calculate the incidence rates. This is a change from the previous editions, where infectious disease was defined as the combined incidence of AIDS, TB and Hepatitis A and B, and three-year averages were used. More information on this definition shift is available on ppp. Historical data has been adjusted to fit the new definition in order to allow for comparisons, however the infectious disease rate in this edition is not comparable to infectious disease rates in previous year’s print editions. The 2011 ranks are based on 2008 and 2009 data (Mortality and Morbidity Weekly Reports, Centers for Disease Control and Prevention).

The incidence of infectious disease is an indication of the toll that infectious disease is placing on the population. Transmission of infectious diseases can often be prevented and controlled through various approaches, including immunization programs, proper handwashing, use of safe cooking practices and other public health programs.

The incidence of infectious disease per 100,000 population varies from a reported low of less than four cases per 100,000 population in West Virginia, Vermont and Connecticut to a reported high of more than 20 cases in Minnesota and Alaska. The national average is 10.3 cases per 100,000 population, down from 11.4 cases per 100,000 population in 2010, using the new definition.

 

Air Pollution measures the fine particulates in the air we breathe. It is the population-weighted average exposure to particulates 2.5 micron and smaller for each county reporting within a state. Air pollution is monitored in many counties where population density is significant and/or where there have been pollution concerns in prior years. Population weighting of the county data adjusts the information to reflect the actual number of people potentially exposed to the particulate. In counties where pollution data is not available, the population was assumed to be exposed to the background level of particulate in the air quality control region and/or state. Background levels are estimated to be the average of the lowest measures in each region or state for each of the last three years. The 2011 ranks are based on 2008 to 2010 data (U.S. Environmental Protection Agency, Washington, D.C. and the U.S. Census Bureau, Washington, D.C.).

Health studies have shown a significant association between exposure to fine particles and premature death from heart or lung disease. Other adverse effects on health from air pollution include decreased lung function, aggravated asthma, development of chronic bronchitis, irregular heartbeat, and nonfatal heart attacks. See www.epa.gov/air/particlepollution/health.html for more information.
Air pollution varies from a low of 5.2 micrograms of fine particulate per cubic meter in Wyoming to 15.1 micrograms of fine particulate per cubic meter in California. The national average is 10.8 micrograms of fine particulate per cubic meter, down slightly from 11.4 micrograms in the 2010 Edition and 12.5 micrograms in 2006.

Public and Health Policies

Three measures are used to represent public and health policies and programs: public health funding, immunization coverage and lack of health insurance. These measures are indicative of the availability of resources and the extent of the program’s reach to the public.
 
Every state has many excellent and effective public health programs, too numerous and individualized to list, that contribute to the overall health of the population but are not explicitly included in these rankings. Contact your state public health officials to obtain additional information about programs in your state that are enacted to optimize individual and community health. Each state’s health department website is listed on the corresponding state snapshot. Individuals can also see the spectrum of options available to states and communities by visiting www.thecommunityguide.org, a website that provides a systemic review of programs and evidence-based recommendations for health and community officials.
 
Lack of Health Insurance measures the percentage of the population not covered by private or public health insurance. The 2011 ranks are based on 2009 and 2010 data (Current Population Survey, 2008 to 2011 Annual Social and Economic Supplements, Washington, D.C., U.S. Census Bureau).
 
Individuals without health insurance have greater difficulty accessing the health care system, frequently are not able to participate in preventive care programs, and can add substantially to the cost of health care due to delayed care and emergency department treatment.

The rate of uninsured population ranges from 5.0 percent in Massachusetts to 25 percent in Texas. The national average is 16.2 percent (over 50 million people) uninsured. If the United States as a whole could emulate the best state, the number of uninsured would decrease by over 35 million people.

Greatest Decreases in Lack of Health Insurance (Change in percentage of people insured)

 

Public Health Funding measures the dollars per person that are spent on public or population health through funding from the Centers for Disease Control and Prevention, Health Resources Services Administration and the state. This does not include spending from other sources such as county or city governments nor does it include state spending for health that is included under other departmental spending such as education and transportation. The 2011 ranks are based on 2009 and 2010 data (Trust for America’s Health, Washington, D.C.).  

High spending on public health programs are indicative of states that are proactively implementing preventive and education programs targeted at improving the health of at-risk populations within a state. Recent research has shown that an investment of $10 per person per year in proven community-based programs to increase physical activity, improve nutrition, and prevent smoking and other tobacco use could save the country more than $16 billion annually within five years. This is a return of $5.60 for every $1 invested (http://healthyamericans.org/reports/prevention08/Prevention08.pdf).

Public health funding ranges from $150 or more per person in Vermont, Alaska and Hawaii to $40 per person in Wisconsin. The average funding in the United States is $95 per person, a slight increase from $94 in last year’s edition.

 Immunization Coverage is the average of the percentage of children ages 19 to 35 months who have received the following vaccines: Diphtheria, Tetanus, Pertussis (DTP), Poliovirus, Measles, Mumps and Rubella (MMR) and Hepatitis B Vaccine (HepB). This measure was changed in the 2010 Edition due to the effects of a shortage of the HiB vaccine, new vaccine products and a temporary recommendation on HiB vaccinations. This measure does not account for each individual receiving the full series of shots, but rather, individuals receiving individual shots. This caused immunization numbers to be higher than for the previous definition used for Immunization Coverage. The 2011 ranks are based on 2010 data (National Immunization Program, Centers for Disease Control and Prevention).  
           
Early childhood immunization has been shown to be a safe and cost-effective manner of controlling diseases within the population. The Guide to Community Preventive Services has numerous proven methods to increase the rate of vaccinations in a community that include ways to increase the demand in the community, improve access and system-based or provider-based innovations. See their suggestions at http://www.thecommunityguide.org/vaccines/universally/index.html.

Immunization coverage ranges from over 95 percent of children ages 19 to 35 months in New Hampshire and Connecticut to less than 85 percent in Nevada and Montana. In the United States, the average immunization coverage is 90 percent of children ages 19 to 35 months, essentially the same coverage as last year and five years ago.

Clinical Care

Preventive and curative care must be delivered in an effective, appropriate and timely manner. Three measures are included in this section: Early Prenatal Care, Primary Care Physicians and Preventable Hospitalizations. Prenatal care, in one form or another, has been included since the 1990 Edition and Primary Care Physicians and Preventable Hospitalizations were added in the 2007 Edition.

Early Prenatal Care is the percentage of pregnant women who receive care within the first trimester of pregnancy and was revised in the 2010 Edition. Early prenatal care is derived directly from the birth certificate. In 2003, CDC’s National Center for Health Statistics (NCHS) introduced a revised live birth certificate, however implementation of the new certificate has not occurred across all 50 states. Because states are using different versions of the birth certificate, a state-to-state direct comparison of prenatal care measures cannot be made, and a national average cannot be calculated. Therefore, the prenatal care measure only compares one state to another state using the same birth certificate and their scores are calculated based upon their peer group. Early prenatal care is not adjusted for frequency of care, continuation of care, age or race. The 2011 ranks are based on 2008 data (National Center for Health Statistics at http://205.207.175.93/VitalStats/ReportFolders/reportFolders.aspx).  

Prior to the 2010 Edition, a broader definition of prenatal care was used that included frequency and timeliness of prenatal care throughout the pregnancy. The 1990 through 2004 Editions of the report defined Prenatal Care using the Kessner Index and 2005 through 2009 Editions used the Kotelchuck (APCNU) index.

Prenatal care measures how early women are receiving the care they require for a healthy pregnancy and development of the fetus. Mothers who do not receive prenatal care are three times more likely to deliver a low birth weight baby than mothers who received prenatal care, and babies are five times more likely to die without the care (http://mchb.hrsa.gov/programs/womeninfants/prenatal.html). Early prenatal care allows health care providers to identify and address health conditions and behaviors that may reduce the likelihood of a healthy birth, such as smoking and drug and alcohol abuse.

 Primary Care Physicians is a measure of access to primary care for the general population as measured by number of primary care physicians per 100,000 population. Primary care physicians include all those who identify themselves as Family Practice physicians, General Practitioners, Internists, Pediatricians, Obstetricians or Gynecologists. The 2010 ranks are based on 2009 data (American Medical Association, Physician Characteristics and Distribution in the United States, 2011 Edition, Chicago, Ill. Data used with permission).

Primary care physicians provide a combination of direct care to the patient and, as necessary, counsel the patient in the appropriate use of specialists and advance treatment locations. This measure reflects the availability of physicians to assist the population with preventative and regular care. The number of primary care physicians per 100,000 population will change because of changing state population, physician retirements, new physicians, and physicians moving between states and specialties.

Primary care physicians range from 192 physicians per 100,000 population in Massachusetts to 78 physicians per 100,000 in Idaho. The national average is 121 primary care physicians per 100,000 population, essentially unchanged in the last few years.

Preventable Hospitalizations is a measure of the discharge rate from hospitals for ambulatory care-sensitive conditions. Ambulatory care–sensitive conditions are those “for which good outpatient care can potentially prevent the need for hospitalization, or for which early intervention can prevent complications or more severe disease ⁵." It is not adjusted by characteristics of the population served, such as age or health status. The 2011 ranks are based on 2009 data (The Dartmouth Atlas of Health Care, The Dartmouth Institute for Health Policy and Clinic Practice, Lebanon, N.H.).  

Preventable hospitalizations reflect how well a population uses the various delivery options for necessary care. These hospitalizations can often be reduced by strong outpatient care systems and include conditions such as adult asthma, bacterial pneumonia, congestive heart failure, chronic obstructive pulmonary disease, diabetes, low birth weight, urinary tract infection and other conditions. These discharges are also highly correlated with general admissions and reflect the tendency for a population to overuse the hospital setting as a site for care.

The rate of preventable hospitalizations ranges from a low of under 40 discharges per 1,000 Medicare enrollees in Hawaii and Utah to over 100 discharges per 1,000 Medicare enrollees in West Virginia and Kentucky. The national average is 68.2 discharges per 1,000 Medicare enrollees, down from 70.6 discharges last year and 82.5 in the 2001 Edition.

 

Health Outcomes

Health outcomes include the prevalence of adults with diabetes, mortality rates, the disparity among outcomes in a state and the quality of life. These measures represent the burden placed on the overall health of a population by chronic disease, death, disparity and depressed quality of life. Measures range from counting days in which people feel their normal activities are limited due to poor health to disease-specific mortality and years of potential life lost.

Outcomes are traditionally measured using mortality measures which include premature death, infant mortality, cancer and cardiovascular mortality. While these measures overlap significantly, they do present different views of mortality outcomes of a population. Two measures of the quality of life – poor mental health days and poor physical health days – are also included and defined as the number of days in the previous 30 days when a person indicates their activities are limited due to mental or physical health difficulties. Disparity in health outcomes is now explicitly captured in the Geographic Disparity measure.

 Diabetes is the percentage of adults who have been told by a health professional that they have diabetes, excluding pre-diabetes and gestational diabetes. Diabetes was changed in this Edition from a supplemental measure to an outcome measure to account for the impact of treating and managing chronic diseases in the U.S. The 2011 ranks are based on self-report data from CDC’s 2010 BRFSS data.  

Diabetes is a long-term illness that is managed through lifestyle changes and healthcare interventions. It is a major cause of heart disease and stroke, the leading cause of kidney failure, non-traumatic lower-limb amputations, and new blindness in adults. It is also the 7th leading cause of death in the United States ⁶.

Studies have indicated that the onset of Type II Diabetes can be prevented through weight loss, increased physical activity and improving dietary choices. The National Diabetes Prevention Program was created to bring evidence-based interventions to prevent diabetes to communities across the country. In addition to this program, additional diabetes information is available at the National Center for Chronic Disease Prevention and Health Promotion, CDC , CDC publications about diabetes and the American Diabetes Association.

The percent of adults with diabetes ranges from over 12 percent of the population in Mississippi and Alabama to 5.3 percent in Alaska. The national average is 8.7 percent, up from 7.3 percent in the 2010 Edition.

 

Poor Mental Health Days is the average number of days in the previous 30 days that a person could not perform work or household tasks due to mental illness. The self-reported data relies on the accuracy of each respondent’s estimate of the number of limited activity days in the previous 30 days. The 2011 ranks are based on 2010 data (Behavioral Risk Factor Surveillance System, Centers for Disease Control and Prevention).

Poor mental health days are a general indication of the population’s ability to function on a day-to-day basis. It highlights the impact on overall health that occurs when mental health prohibits an individual from accomplishing everyday activities.

The number of poor mental health days in the previous 30 days ranges from an average of 2.3 days in South Dakota to 4.5 days in West Virginia. The average number of poor mental health days in the previous 30 days for the United States is 3.5 days, essentially unchanged from prior editions.

Poor Physical Health Days is the average number of days in the previous 30 days that a person could not perform work or household tasks due to physical illness. The self-reported data relies on the accuracy of each respondent’s estimate of the number of limited activity days in the previous 30 days. The 2011 ranks are based on 2010 data (Behavioral Risk Factor Surveillance System, Centers for Disease Control and Prevention).

Poor physical health days are another general indication of the population’s ability to function on a day-to-day basis. When physical health prohibits an individual from accomplishing everyday activities, overall health is influenced.

The number of poor physical health days in the previous 30 days ranges from an average of 2.6 days in Minnesota and South Dakota to over 4.9 days in West Virginia. The average number of poor physical health days in the previous 30 days for the United States is 3.7 days and has remained essentially unchanged for the last seven years.

 

Geographic Disparity measures the variation in the age-adjusted mortality rate among counties within a state. It is the standard deviation of the three-year average, age-adjusted all-cause mortality rate for all counties within a state divided by the three-year age-adjusted all-cause mortality rate for the state. The lower the percent, the closer each county is to the state average and the more uniform the mortality rate is across the state. For counties with fewer than 20 deaths in the three-year period (about 20 to 30 counties in the United States each year), the county was assumed to have an age-adjusted death rate equal to the state’s age-adjusted death rate and thus has no effect on the geographic disparity of the state. Geographic Disparity was a new measure in the 2008 Edition. The 2011 ranks are based on 2005 to 2007 data (National Center for Health Statistics. Centers for Disease Control and Prevention).

Ideally, health and mortality should be equal among the populations of every county within a state and not vary based upon the physical location where a person lives. Many factors differ among counties, including natural features such as altitude, latitude, moisture and temperature and man-made features such as land use, population density, roads and communications. Regardless of these variations, the mortality rate should still be comparable. This measure indicates how equal the outcomes are across the state.

Geographic disparity varies from a low geographic disparity of less than 5 percent in Delaware and Vermont to a high geographic disparity of more than 25 percent in South Dakota. For the United States as a whole, the geographic disparity among all counties is 17.2 percent, essentially stabilizing after a consistently upward trend between the 2004 to the 2008 Editions.

Infant Mortality measures the number of infant deaths that occur before age 1 per 1,000 live births. The 2011 ranks are based on a two-year average using 2007 and 2008 data (National Center for Health Statistics, Washington, D.C.).

Infant mortality is associated with many factors surrounding birth, including but not limited to: maternal health, prenatal care, and access to quality healthcare. The nation’s overall infant mortality rate is consistently higher than other developing countries and significant racial and ethnic disparities exist (http://www.cdc.gov/nchs/data/databriefs/db09.htm). Reducing infant mortality is a goal of Healthy People 2020.

Infant mortality varies greatly among states, from less than 5 deaths per 1,000 live births in New Hampshire, Vermont and Utah to 10 deaths per 1,000 live births in Mississippi. The national average is 6.7 deaths per 1,000 live births, stable since the 2004 Edition. States with a low number of births will experience more fluctuations in the two-year average infant mortality rate than states with a higher number of births.

Greatest Decreases in Infant Mortality (Change is number of fewer deaths within the first year of life per 1,000 live births)

 

Cardiovascular Deaths measures the three-year average, age-adjusted number of deaths attributed to cardiovascular diseases, including but not limited to heart disease and stroke, per 100,000 population. The 2011 ranks are based on 2006 to 2008 data (National Center for Health Statistics, Centers for Disease Control and Prevention).

Cardiovascular deaths are an indication of the toll cardiovascular disease places on the population. In the United States, heart disease and stroke are currently the leading and fifth most common cause of death, respectively16. To reduce this burden, Million Hearts, a new national initiative  to prevent one million heart attacks and strokes over the next five years, was recently established.⁷ Additional information on the initiative is available at http://millionhearts.hhs.gov/.

Deaths from cardiovascular disease vary from a low of 197.2 deaths per 100,000 population in Minnesota to 366.4 deaths per 100,000 population in Mississippi. The national average is 270.4 deaths per 100,000 population, down from 278.2 deaths per 100,000 population last year and 405.1 deaths per 100,000 population in 1990. The use of mortality data does not reflect the full burden of cardiovascular disease on the nation, as data indicates that despite declining cardiovascular mortality rates, more individuals are living with cardiac disease as new procedures prolong the lives of these individuals.
 

Greatest Decreases in Cardiovascular Deaths (Change is number of fewer deaths per 100,000 population)

 

Cancer Deaths measures the three-year average, age-adjusted number of deaths attributed to cancer per 100,000 population. The 2010 ranks are based on 2006 to 2008 data (National Center for Health Statistics. Centers for Disease Control and Prevention). 

Cancer is the second leading cause of death in the United States16 and the cancer death measure is an indication of the toll it places on the population. Opportunities exist to reduce the risk of developing some cancers and to prevent others. More information on the cancer burden in the U.S. is available at http://www.cdc.gov/chronicdisease/resources/publications/AAG/dcpc.htm.

The rate varies from less than 160 cancer deaths per 100,000 population in Utah and Hawaii to 220 or more deaths per 100,000 population in West Virginia and Kentucky. The national average is 190.8 deaths per 100,000 population, a decrease of 0.7 deaths per 100,000 population from the 2010 Edition and a decrease of only 6.7 deaths per 100,000 population from the 1990 Edition. Cancer deaths peaked in 1996 when the national rate was 205.5 deaths per 100,000 population.

Greatest Decreases in Cancer Deaths (Change is number of fewer deaths per 100,000 population)

 

Premature Death measures the loss of years of life due to death before age 75 as defined by the Centers for Disease Control and Prevention’s Years of Potential Life Lost (YPLL-75). Thus, the death of a 25-year-old would account for 50 years of lost life, while the death of a 60-year-old would account for 15 years. The 2010 ranks are based on 2008 data (Centers for Disease Control and Prevention).

Premature death is an indication of the number of useful years of life that are not available to a population due to early death. According to 2008 mortality data, cancer, unintentional injury, heart disease, suicide and deaths occurring during the perinatal period are the top five causes of premature death in the United States (National Center for Health Statistics, CDC). Often causes of early death are preventable through education, health care access and public health programs.

The age-adjusted data vary from less than 5,500 years lost per 100,000 population in Minnesota, Massachusetts and New Hampshire to more than 10,000 years lost per 100,000 population in Arkansas, Oklahoma, Mississippi, Louisiana and Alabama. The national average is 7,279 years lost before the age of 75 per 100,000 population, 97 fewer years lost than in the 2010 Edition. Premature death has slowly declined since the 2008 Edition, from 7,490 years lost before age 75 per 100,000 population to the current rate.

Greatest Decreases in Premature Death (Change is number of fewer years lost before age 75 per 100,000 population)

 

Supplemental Measures

The core measures used in the Rankings represent a small fraction of the measures available to the general public and to public health officials. The America’s Health Rankings® website contains additional measures that are useful in understanding the health of your state and provide information for more in-depth analysis.

The summary definition table contains a brief definition of the supplemental measures.

Cholesterol Check: The National Cholesterol Education Program (NCEP) recommends that adults aged 20 years or older have their cholesterol checked every five years. A simple blood test can measure total cholesterol levels, including LDL (low-density lipoprotein, or "bad" cholesterol), HDL (high-density lipoprotein, or "good" cholesterol), and triglycerides. Approximately one in six people are considered to have high cholesterol.⁸ Factors that influence individuals receiving a blood cholesterol check include access, cost, education and motivation.
 
These data are collected through the Behavioral Risk Factor Surveillance System by the CDC.

In Massachusetts, Rhode Island and Maryland, over 83 percent of adults had their cholesterol checked in the last five years. In Utah and Idaho, fewer than 70 percent of adults were checked.

The National Heart, Lung and Blood Institute at the National Institutes of Health provides additional background information on cholesterol and actions you can take to manage high cholesterol.

Dental Visit, Annual: Oral health is a vital part of a comprehensive preventive health program. The Division of Oral Health at the CDC notes, “There are threats to oral health across the lifespan. Nearly one-third of all adults in the United States have untreated tooth decay. One in seven adults aged 35 to 44 years has gum disease; this increases to one in every four adults aged 65 years and older. In addition, nearly a quarter of all adults have experienced some facial pain in the past six months. Oral cancers are most common in older adults, particularly those over 55 years who smoke and are heavy drinkers.”⁹ Factors that influence individuals receiving dental care include access, cost, education and motivation.

These data are collected through the Behavioral Risk Factor Surveillance System by the CDC.

In Connecticut and Massachusetts, over 80 percent of adults had a dental visit within the last year. In Mississippi and Oklahoma, fewer than 60 percent of adults had a visit in the last year.

Additional information on oral health can be obtained from CDC’s Division of Oral Health and from the American Dental Association. Both organizations address questions about personal oral health and community programs to improve overall oral health, such as water fluoridation.

Physical Activity: Regular physical activity is one of the most important things you can do for your health. It can help¹⁰ :

• Control your weight
• Reduce your risk of cardiovascular disease
• Reduce your risk for Type 2 diabetes and metabolic syndrome
• Reduce your risk of some cancers
• Strengthen your bones and muscles
• Improve your mental health and mood
• Improve your ability to do daily activities and prevent falls, if you're an older adult
• Increase your chances of living longer

These data are collected through the Behavioral Risk Factor Surveillance System by the CDC. These physical activities range from walking through exercise programs, so the range includes activities that are available to almost every individual.

In Oregon, Utah, Vermont, Colorado, Washington, Minnesota, Hawaii, New Hampshire and Idaho, over 80 percent of adults participate in physical activities. In Mississippi, West Virginia, Alabama and Louisiana fewer than 70 percent participate.

The CDC presents guidelines for physical activities for adults, children and older adults at http://www.cdc.gov/physicalactivity/everyone/guidelines/index.html.

Diet Fruit and Vegetables:According to the Dietary Guidelines for Americans published by the CDC, a healthy eating plan¹¹ :

• Emphasizes fruits, vegetables, whole grains, and fat-free or low-fat milk and milk products
• Includes lean meats, poultry, fish, beans, eggs, and nuts
• Is low in saturated fats, trans fats, cholesterol, salt (sodium), and added sugars
• Stays within your daily calorie needs

Data collected for this measure focus on the consumption of vegetables and fruits at the recommended five portions per day. These data are collected through the Behavioral Risk Factor Surveillance System by the CDC.

Almost 30 percent of Vermont residents eat their veggies compared to less than 15 percent of Oklahoman residents.

Nutritional information is abundant and overwhelming, but two sound starting points for information are the CDC resources about healthy weight and the National Heart, Lung and Blood Institute DASH nutrition plan. The DASH eating plan was originally developed as an eating plan to reduce high blood pressure, i.e. hypertension. (DASH stands for Dietary Approaches to Stop Hypertension.) However, the plan also represents a healthy approach to eating for those who do not have a problem with hypertension.

Access to healthy food can also be a challenge. The United States Department of Agriculture identifies areas of the country that are “food deserts”, areas where healthy, wholesome foods are less readily available.

Teen Birth Rate: Prevention of teen and unplanned pregnancy is an important part of a healthy community. The CDC notes, “In 2009, a total of 409,840 infants were born to 15−19 year olds, for a live birth rate of 39.1 per 1,000 women in this age group. Nearly two-thirds of births to women younger than age 18 and more than half of those among 18−19 year olds are unintended.”¹² CDC continues on to state “Teen pregnancy accounts for more than $9 billion per year in costs to U.S. taxpayers for increased health care and foster care, increased incarceration rates among children of teen parents, and lost tax revenue because of lower educational attainment and income among teen mothers.”¹³ . A general trend of decreasing rates has resumed with the latest data after rising a few years ago.

Data collected for this measure focus on the rate of birth to mothers age 15 through 19. These data are collected by the CDC.

Teen birth is lowest in New Hampshire at 19.8 births per 1,000 mothers age 15 to 19 and the highest in Mississippi with 65.7 births per 1,000 mothers age 15 to 19.

A valuable resource for further information about teen and unplanned pregnancy is available from The National Campaign to Prevent Teen and Unplanned Pregnancy.

Low Birthweight: Low birthweight is the category of babies weighing less than 2,500 grams (5 pounds, 8 ounces) at birth. Low birthweight babies are more likely than babies of normal weight to have health problems during the newborn period. Serious medical problems are most common in babies born at very low birthweight and include respiratory distress syndrome; bleeding in the brain; patent ductus arteriosus, a heart problem common in premature babies; necrotizing enterocolitis, an intestinal problem that usually develops two to three weeks after birth; and retinopathy of prematurity, an abnormal growth of blood vessels in the eye that can lead to vision loss.¹⁴
Fewer than six percent of babies are born with low birthweight in Alaska, Oregon, Washington, Minnesota and South Dakota while 10 percent or more are born with low birthweight in Mississippi, Louisiana, Alabama, South Carolina, Georgia and West Virginia.
Low birthweight can be addressed in multiple ways, including¹⁵ :

• Expand access to medical and dental services, taking a lifespan approach to health care
• Focus intensively on smoking prevention and cessation
• Ensure that pregnant women get adequate nutrition
• Address demographic, social, and environmental risk factors

Preterm Birth: Preterm birth refers to the birth of a baby of less than 37 weeks gestational age. Late-preterm birth refers to babies born between 34 and 36 weeks of pregnancy. More than 70 percent of preterm babies are born at this time. While these babies are usually healthier than babies born earlier, they are three times more likely to die in the first year of life than full-term infants. They are also at increased risk of newborn health problems, including breathing and feeding problems. Some late-preterm births result from early induction of labor or cesarean delivery due to pregnancy complications. However, in some cases, early delivery may occur without good medical justification.¹⁶

In Alaska and New Hampshire, fewer than 10 percent of babies are born preterm. In Mississippi, over 14 percent are born preterm.

Chronic Disease: Five diseases are included in this category: cardiac heart disease, high cholesterol, heart attack, stroke and hypertension (high blood pressure). These diseases are long-term illnesses that many individuals can manage through lifestyle changes and healthcare interventions. However, they do place a burden on many of the affected individuals by constraining options and activities available to them and can result in expensive and ongoing expenditures for health care.

All measures are self-reported by respondents to the Behavioral Risk Factor Surveillance System for the following questions.

Supplemental Chronic Disease Measures

Resources for heart and vascular diseases are at National Heart, Lung and Blood Institute as well as at the Division for Heart Disease and Stroke Prevention, CDC.

Median Household Income: Median household income is the amount of income that divides the income distribution into two equal groups, half with income above that amount, and half with income below that amount. Household income reflects the ability for that household to afford aspects of a healthy lifestyle, including preventive medicine and curative care not provided to the individual through government, business, trade groups or other sources.

Data for household income is from the U.S. Census Bureau, Current Population Survey, Annual Social and Economic Supplements.

Personal Income: An individual’s income reflects the ability of that individual to afford aspects of a healthy lifestyle, preventive medicine and curative care not provided to the individual through government, business, trade groups or other sources. Personal income has also been shown to be negatively correlated to morbidity and mortality, meaning that higher income individuals experience lower illness and death.¹⁷

Data for personal income is from the Regional Economic Information System, Bureau of Economic Analysis, U.S. Department of Commerce. Per capita personal income is total personal income divided by total mid-year population.

Unemployment Rate: For many individuals, their employer is the source for their healthcare insurance. For most, employment is the source of income for sustaining a healthy life and for accessing healthcare.
The Bureau of Labor Statistics, U.S. Department of Labor releases unemployment figures monthly and annually. The official definition of the unemployment rate is “total unemployed, as a percent of the civilian labor force” and is the figure most widely published by the media.  

Data are available for the most recent annual unemployment rate and the the August 2011 unemployment rate.

Underemployment Rate: Many suggest that the official unemployment rate does not reflect the full impact of employment on the market. The Bureau of Labor Statistics uses an expanded definition to allow for individuals who are no longer seeking employment, those employed only part-time when they desire full-time work and workers who are only marginally attached, that is persons who currently are “neither working nor looking for work but indicate that they want and are available for a job and have looked for work sometime in the recent past.”

Income Disparity (Gini): The Gini coefficient is a common measure of income inequality. It varies between 0, which reflects complete equality of income and 1, which indicates complete inequality (one person has all the income or consumption, all others have none). Historically, the U.S. index has varied from .386 in 1968 to .469 in 2010 (http://www.census.gov/prod/2011pubs/acsbr10-02.pdf).

There is debate among the public health and economic communities as to the effect of income disparity on the health of a population. However, that need not be resolved to acknowledge that income disparity does play a factor in how a community will develop plans and take actions to change health. As such, income disparity provides a valuable description of the environment in which health improvement programs must be implemented.

The source for the data is U.S. Census Bureau, Current Population Survey, 1978 to 2010 Annual Social and Economic Supplements.

Most developed European nations and Canada have Gini indices between .24 and .36. (The Gini Index, which is the Gini coefficient times 100, is reported for other countries by the Central Intelligence Agency at https://www.cia.gov/library/publications/the-world-factbook/fields/2172.html.