Air Pollution

Air pollution is based upon the Environmental Protection Agency (EPA) annual estimate of PM2.5 in each county weighted by the population of that county. For counties without an estimated exposure, the lowest estimated exposure for the Air Quality Control Region is used. If the county still does not have an estimate, the minimum state value is used for the county. Air pollution is calculated using the most recent three years of data available.

American Community Survey

The American Community Survey (ACS) is an ongoing survey conducted by the US Census Bureau that provides information on a yearly basis about our nation and its people. Data are analyzed in one and five year summations. Data are accessed using the American Factfinder interface.

Behavioral Risk Factor Surveillance System Data (BRFSS)

BRFSS data are analyzed using STATA v15.1 to account for the complex survey design. Data was limited to women aged 18 to 44 for the Health of Women and Children Report. Data was limited to adults aged 65 and older for the Senior Report. Responses of “refused”, “don’t know” or “not sure” are excluded from the analysis, but are reflected in standard error and confidence interval estimates. Prevalence estimates were also calculated by sex, age group, race/ethnicity, urbancity, education and income level subpopulations. For calculating subpopulation estimates, the population of interest is specified in a manner that avoids deletion of cases. This ensures an accurate variance estimation.
Population estimates for measures from BRFSS are calculated using the specified survey weights and represent the non-institutionalized adult population aged 18 and older. Discrepancies between prevalence estimates and population estimates are likely due to random sampling error and non-random response biases.
Estimates were suppressed if the denominator was less than 50 or the random standard error was greater than or equal to 30 percent.
When multiple years of data from BRFSS are used to obtain an estimate, weights are adjusted to represent the average population over the multiple year period.
BRFSS made two changes in 2011 to improve their survey methodology. Due to these changes, 2011 to present BRFSS data are not directly comparable to previous years.
CDC publishes estimates of the U.S. prevalence for the total adult population as the median value of the 50 states and the District of Columbia. This convention is also used for America’s Health Rankings Annual report. The estimates for all subpopulations are based upon the mean of all applicable records. The mean is also used for the following reports that feature a specific population: America’s Health Rankings Health of Women and Children, America's Health Rankings Senior, America’s Health Rankings Health of Those Who Have Served, and America’s Health Rankings Health of Women Who Have Served.

Concentrated Disadvantage

Concentrated disadvantage is calculated at the census tract level from five Census variables: 1) percent of individuals below the poverty line, 2) percent of individuals on public assistance, 3) percent female-headed households, 4) percent unemployed, and 5) percent less than age 18. The percentages of each individual indicator are z-score transformed. The resulting value are averaged into an overall index of concentrated disadvantage. A tract is designated as concentrated disadvantage if this index is at or above the 75th percentile of all tracts in the U.S. The percent of all households in the state located in census tracts is reported as concentrated disadvantage.
More details on the methodology are available from Association of Maternal and Child Programs LIfe Indicators Program.

Food Insecurity

Food insecurity is obtained from the USDA annual report on Food Security in the United States. We report the percentage of households categorized as low food security available by state in the report.

Guttmacher Institute

The Guttmacher Institute is a leading research and policy organization committed to advancing sexual and reproductive health and rights in the United States and globally. From their periodic report, Contraceptive Needs and Services, we utilize the data labeled “Percentage of the need for publicly funded contraceptive services met by all publicly supported providers and by Title X-funded clinics, by state”. The definitions applicable for this dataset are:
  • Women are defined as being in need of contraceptive services and supplies if they are aged 13–44 and meet the following three criteria during all or part of a given year: (1) they were sexually active (estimated as those who have ever had voluntary vaginal intercourse); (2) they were able to conceive (neither they nor their partner had been contraceptively sterilized, and they did not believe that they were infecund for any other reason); and (3) they were neither intentionally pregnant nor trying to become pregnant.
  • Women are defined as in need of publicly funded contraceptive services and supplies if they meet the above criteria and have a family income below 250 percent of the federal poverty level. In addition, all women younger than 20 who need contraceptive services, regardless of their family income, are assumed to need publicly funded care because of their heightened need—for reasons of confidentiality—to obtain care without depending on their family’s resources or private insurance.
  • Publicly funded contraceptive services and supplies are provided through two main channels. A publicly funded clinic is a site that offers contraceptive services to the general public and uses public funds to provide free or reduced-fee services to at least some clients. These sites may be operated by a diverse range of provider agencies, including public health departments, Planned Parenthood affiliates, hospitals, federally qualified health centers (FQHCs) and other independent organizations. In this report, these sites are referred to as “clinics;” other Guttmacher Institute reports may use the synonymous term “centers.” In addition, some private providers offer Medicaid-funded services.

Health Care Associated Infections (HAI) Policies

Six HAI types and four policy-related items are measured by the Centers for Disease Control and Prevention to track progress toward reducing HAIs.
The six HAI types include:
  • Central-line associated bloodstream infections
  • Catheter-associated urinary tract infections
  • Surgical site infections -from abdominal hysterectomy
  • Surgical site infections -from colon surgery
  • Hospital-onset Clostridium difficile infections
  • Hospital-onset Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia
Four policy-related items include:
  • Is there a state reporting mandate?
  • Does the state health department have access to the HAI data?
  • Is data quality checked for quality?
  • Is additional data review conducted that matches health records with reports?

Infant Mortality

Includes all causes of death in infants under the age of 1 year. The measure is presented as a two-year moving average.
  • Data for the Annual Report are from the CDC WONDER Mortality file.
  • Data for the Health of Women and Children Report, including subpopulation data, are from the CDC WONDER Linked Birth/Infant Deaths file.

National Alliance to End Homelessness

The method used to calculate Homeless Family Households is from the National Alliance to End Homelessness “The State of Homelessness Report”. The number of homeless families is obtained from the annual US Department of Housing and Urban Development Annual Homeless Assessment Report (AHAR) to Congress, Part 1. The total number of households is obtained from the American Community Survey.

National Immunization Survey

The National Immunization Surveys are a group of phone surveys used to monitor vaccination coverage among children 19 to 35 months, adolescents 13 to 17 years, and flu vaccinations for children 6 months to 17 years. The surveys are sponsored and conducted by the National Center for Immunization and Respiratory Diseases (NCIRD) of the Centers for Disease Control and Prevention (CDC).

National Health Interview Survey

The National Health Interview Survey (NHIS) is the principal source of information on the health of the civilian noninstitutionalized population of the United States and is one of the major data collection programs of the National Center for Health Statistics, in the Centers for Disease Control and Prevention. The survey was authorized by the National Health Survey Act of 1956 and was initiated in July 1957.

National Intimate Partner and Sexual Violence Survey

The National Intimate Partner and Sexual Violence Survey (NISVS) is an ongoing survey that collects the most current and comprehensive national- and state-level data on intimate partner violence, sexual violence and stalking victimization in the United States.

National Survey of Children's Health (NSCH)

Estimates using data from the NSCH in this report were obtained from the data query results table on the Data Resource Center for Child & Adolescent Health, a project of the Child and Adolescent Health Measurement Initiative. Population estimates for measures from NSCH are calculated using the specified survey weights and represent the non-institutionalized child population aged 0 to 17 years in the U.S. and in each state and the District of Columbia who live in housing units. Discrepancies between prevalence estimates and population estimates are likely due to random sampling error and non-random response biases. Missing values due to non-response or a “don’t know” response are not included in the denominator when calculating prevalence estimates and weighted population counts. For all measures included in this report except medical home for special care child, the proportion of missing values is less than 2 percent. One measure this year, well-baby check, was calculated in-house using STATA v15.1 to account for the complex survey design.
The NSCH underwent a redesign in 2016. Data from the 2016 survey are not comparable to previous iterations of the NSCH and NS-CSHCN. The 2016 survey includes changes to data collection and sampling methods, as well as the elimination or alteration of some survey questions. In 2016, the NSCH and NS-CSHCN were also combined into a single self-administered questionnaire. Please refer to www.childhealthdata.org for additional information.

National Survey on Drug Use and Health

The National Survey on Drug Use and Health (NSDUH) The National Survey on Drug Use and Health (NSDUH) measures the use of illegal drugs, prescription drugs, alcohol, tobacco, mental disorders, treatment, and co-occurring substance use and mental disorders. Estimates of substance use and mental illness at the national, state, and sub-state levels are available. NSDUH data also help to identify the extent of substance use and mental illness among different sub-groups, estimate trends over time, and determine the need for treatment services.

National Vital Statistics System (NVSS)

NVSS data are obtained through the CDC WONDER Online Databases. For each NVSS measure, the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) codes used are defined below. When multiple years of data are combined and age adjusted, a non-standard population representing the midpoint of the years selected is used. This non-standard population includes all origins, races and genders.
Drug deaths ICD-10 codes:
  • X40 (Accidental poisoning by and exposure to nonopioid analgesics, antipyretics and antirheumatics)
  • X41 (Accidental poisoning by and exposure to antiepileptic, sedative-hypnotic, antiparkinsonism and psychotropic drugs, not elsewhere classified)
  • X42 (Accidental poisoning by and exposure to narcotics and psychodysleptics [hallucinogens], not elsewhere classified)
  • X43 (Accidental poisoning by and exposure to other drugs acting on the autonomic nervous system)
  • X44 (Accidental poisoning by and exposure to other and unspecified drugs, medicaments and biological substances)
  • X60 (Intentional self-poisoning by and exposure to nonopioid analgesics, antipyretics and antirheumatics)
  • X61 (Intentional self-poisoning by and exposure to antiepileptic, sedative-hypnotic, antiparkinsonism and psychotropic drugs, not elsewhere classified)
  • X62 (Intentional self-poisoning by and exposure to narcotics and psychodysleptics [hallucinogens], not elsewhere classified)
  • X63 (Intentional self-poisoning by and exposure to other drugs acting on the autonomic nervous system)
  • X64 (Intentional self-poisoning by and exposure to other and unspecified drugs, medicaments and biological substances)
  • X85 (Assault by drugs, medicaments and biological substances)
  • Y10 (Poisoning by and exposure to nonopioid analgesics, antipyretics and antirheumatics, undetermined intent)
  • Y11 (Poisoning by and exposure to antiepileptic, sedative-hypnotic, antiparkinsonism and psychotropic drugs, not elsewhere classified, undetermined intent)
  • Y12 (Poisoning by and exposure to narcotics and psychodysleptics [hallucinogens], not elsewhere classified, undetermined intent)
  • Y13 (Poisoning by and exposure to other drugs acting on the autonomic nervous system, undetermined intent)
  • Y14 (Poisoning by and exposure to other and unspecified drugs, medicaments and biological substances, undetermined intent)
Cardiovascular deaths ICD-10 codes:
  • I10-I15 (Hypertensive diseases)
  • I20-I25 (Ischaemic heart diseases)
  • I26-I28 (Pulmonary heart disease and diseases of pulmonary circulation)
  • I30-I51 (Other forms of heart disease)
  • I60-I69 (Cerebrovascular diseases)
  • I70-I78 (Diseases of arteries, arterioles and capillaries)
  • I80-I89 (Diseases of veins, lymphatic vessels and lymph nodes, not elsewhere classified)
  • I95-I99 (Other and unspecified disorders of the circulatory system)
Cancer deaths ICD-10 codes:
  • C00-C97 (Malignant neoplasms)
  • D00-D09 (In situ neoplasms)
  • D37-D48 (Neoplasms of uncertain or unknown behaviour)

Occupational Fatalities

Occupational fatalities for four industries (SPT1TTU - trade, transportation and utilities, SP1PBS - professional and business services, GP2CON - Construction and CP2MFG - Manufacturing) over the last three years are the numerator for this calculation. Where data are missing due to low counts, a number of deaths is estimated based upon the national rate.The denominator is the estimated employment in these four industries (Construction- NIACS 400, Manufacturing-NAICS 500, Trade, transportation and utilities (Utilities -NAICS 300300, Wholesale trade-NAICS 600, Retail trade-NAICS 700 and Transportation-NAICS 800) and Professional and business services (Professional and technical services-NAICS 1200 and Management of companies-NAICS 1300)).
Rates are adjusted in each state to represent the national balance in employment in each industry.

Pregnancy Risk Assessment Monitoring System (PRAMS)

PRAMS is a joint research project by the Centers for Disease Control and Prevention (CDC) and state health departments to examine the health of mothers and infants. Surveys are completed by mothers who recently gave birth, and data on the mother’s pregnancy and her infant are collected. PRAMS is one of the only sources for such data on a state-by-state basis.
The CDC suppressed data from states in which the response rate for the PRAMS survey does not meet the current threshold. For 2015 data, the threshold was a 55 percent response rate. For states that collected PRAMS data but did not meet the reporting threshold for release by the CDC, state health departments were contacted directly and PRAMS data were requested for use in this report. Several states (CA, ID, SD) do not participate in PRAMS but conduct similar surveys. When the questions and survey methodology were deemed to be consistent with PRAMS, those data are presented in this report.
More information on PRAMS can be found at the CDC website.

Premature Death

Includes all causes of death. For the Annual Report this measure is calculated per CDC’s recommendations for years of potential life lost before age 75 using age bands of less than 1 year, 1 to 4 years, 5 to 14 years and then ten year age-bands up to age 75. For age bands with suppressed data, additional years of data are used for the calculation.

Risk of Social Isolation

Risk of Social Isolation is a summary measure with six factors:
  • Percent of seniors that are divorced, separated or widowed
  • Percent of seniors that never married
  • Percent of seniors that live alone
  • Percent of seniors with an income below the poverty level
  • Percent of seniors that have any disability
  • Percent of seniors that have an independent living difficulty
All data are sourced from the American Community Survey using the latest 5-year estimates. Tables B12002, S1810, S1701 and DP02 were downloaded using U.S. Census Bureau American Factfinder.
Other factors not in our risk of social isolation measure but cited in the literature are race/ethnicity; immigration status; level of English proficiency; sexual orientation and gender identity; meaningful social participation; being a caregiver; support of family and community; and rurality.
Counts for each measure (numerator) and the reference population (denominator) were downloaded for each census tract in the U.S. and used to calculate percentages. A z score was then calculated for each census tract relative to the U.S. average and standard deviation of all census tracts. The six z scores were averaged to arrive at the risk of social isolation score for the census tract. Percentiles were generated for each observation based upon the risk of social isolation score.
For county and state estimates, the counts for each measure and the reference population were summed across the geographic area of interest (county or state) and used to calculate county and state level percentages. A z score was calculated for each measure at the county level relative to the mean and standard deviation of all U.S. counties. The same was done at the state level relative to the mean and standard deviation of all states. The six z scores were averaged by county and also by state to generate the risk of social isolation score for the county and for the state. Percentiles were generated for each geographic area based upon the risk of social isolation score.

Please tell us a little more about you

We appreciate you taking the time to help America’s Health Rankings better understand our audiences. Your feedback will allow us to optimize our website and provide you with additional resources in the future. Thank you.

Please select one option which best describes your profession or field of expertise

Journalist or media professional
Health Policy Professional
Public health professional (state, local, or community level)
Health care provider or administrator
Member of an advocacy group or trade organization
Academic, student, or researcher
Government administrator, legislator, or staffer
Concerned citizen
Other
Don't show me this again
Please take a quick survey.