Table of contents:
Our MissionOur ReportsOur Advisory CommitteesAdvisory CouncilAnnual Report Advisory CommitteeSenior Report Advisory CommitteeHealth of Women and Children Report Advisory CommitteeHealth of Those Who Have Served Report Advisory CommitteeHealth Disparities Report Advisory Committee
Our Model and MethodologyIntroductionRankingsMeasures, Weights and DirectionMeasures Selection and ChangesData SourcesDisparity Measures Methodology
Four primary considerations drive the design of America’s Health Rankings® and the selection of the individual measures for each report:
- The overall rankings have to represent a broad range of issues that affect the population’s health.
- Individual measures need to use common health measurement criteria.
- Data have to be available at the state level.
- Data have to be current and updated periodically.
For America’s Health Rankings to continue to meet its objectives, it must evolve and incorporate new information as it becomes available. The advisory committees provide guidance for the evolution of the rankings, balancing the need to change with the desire for comparability over time. Changes are being driven by:
- Acknowledgment that health is more than years lived but also includes the quality of those years
- Data about the quality and cost of health care delivery are becoming available on a comparative basis
- Measurement of additional determinants of health are being initiated and/or improved; and
- Changes in collection methods to improve response rate and accuracy.
In addition to the measures that are used to rank states, each report and the website include numerous supplemental measures. These supplemental measures provide additional information about the health in a state.
2020 Annual Report
This year’s America’s Health Rankings Annual Report introduces a new model that expands the influence of social determinants of health. The community and environment category was expanded into two categories: social and economic factors and physical environment. The policy category was dropped and measures from that area were reassigned to the other categories. Many measures from the prior model were retained and reassigned to a new model category as appropriate. The new model includes 74 measures from 20 data sources. Also new this year are health topics such as economic resources, tobacco use and physical health. For a list of current measures, definitions and source details, see the Measures Table and Data Source Descriptions.
New measures Adverse childhood experiences Avoided care due to cost Climate policies Colorectal cancer screening Crowded housing (economic hardship index) Dedicated health care provider Dental visit Dependency (economic hardship index) Depression Drinking water violations Drive alone to work E-cigarette use Economic hardship index Education — less than high school (economic hardship index) Exercise Flu vaccination Food insecurity Fruit and vegetable consumption High-risk HIV behaviors
Model Revisions High school graduation racial gap High-speed internet Housing with lead risk HPV vaccination Income inequality Insufficient sleep Low birthweight racial gap Multiple chronic conditions Non-medical drug use Non-medical drug use - past month Non-smoking regulation Per capita income (economic hardship index) Poverty (economic hardship index) Premature death racial gap Residential segregation Risk-screening environmental indicators score Severe housing problems Teen births Transportation energy use Volunteerism Voter participation (midterm) Water fluoridation
Retired measures Cancer deaths Cardiovascular deaths Cholesterol check Disconnected youth Disparity in health status Fruits Heart attack Heart disease Immunizations — adolescents Immunizations — HPV females Immunizations — HPV males Infectious disease Injury deaths Median household income Meningococcal immunization Pertussis Salmonella Seat belt use Stroke Underemployment rate Vegetables Voter registration
Measure category assignment changes High school graduation: from behaviors to social and economic factors Occupational fatalities: from community and environment to social and economic factors Public health funding: from policy to social & economic factors Violent crime: from community and environment to social and economic factors Air pollution: from policy to physical environment Childhood immunizations: from policy to clinical care Uninsured: from policy to clinical care Chlamydia: from community and environment to behaviors Excessive drinking: from behaviors to health outcomes Low birthweight: from clinical care to health outcomes Obesity: from behaviors to health outcomes
Data source or methodology changes The following measures are not comparable to previous years’ data: Childhood immunizations. Previously presented by survey year, the new measure is reported by birth cohort. Drug deaths. Previously calculated using three years of data, the new measure uses single year estimates age-adjusted to the current year U.S. population. Dental care providers. Previously provided by the American Dental Association, the new measure is calculated using data from the National Plan and Provider Enumeration System, and the definition has been expanded to include advanced practice therapists. Preventable hospitalizations. Previously provided by the Dartmouth Atlas of Health Care, the new measure uses data from the Centers for Medicare & Medicaid Services, Mapping Medicare Disparities Tool. Primary care providers. Previously provided by Redi-Data, Inc., the new measure is calculated using data from the National Plan and Provider Enumeration System, and the definition has been expanded to include physician assistants and nurse practitioners. Uninsured. Previously calculated using two years of data, the new measure uses single year estimates.
2019 Annual Report
- Thirty-five measures are used to calculate the state health rankings. Two measures, Immunizations–Children and Preventable Hospitalizations, were not updated this year due to no new data being released by the source prior to October 16, 2019; the values and ranks of these two measures are the same as in the 2018 edition. National Immunization Survey-Teen measures are not comparable to prior editions due to a methodology change by the data source. For current measures, definitions and source details visit the Rankings Measures Table.
- These measures are not included in the state rankings calculation but provide context and highlight current and emerging issues affecting the nation’s health. For current supplemental measures, definitions and source details visit the Supplemental Measures Table.
2018 Annual Report Core Measures added in 2018:
- Children in poverty is now calculated from the American Community Survey. Previously the data came from the Current Population Survey Annual Social and Economic Supplement. The Census Bureau recommends using the American Community Survey over the Current Population Survey of Annual Social and Economic Supplement for state-level data as it has less variability. American Community Survey children in poverty data for the previous 10 years are available on the website.
Supplemental Measures added in 2018:
Four measures were added to this year’s report to expand the community & environment measures available from America’s Health Rankings, including:
- Adverse Childhood Experiences are stressful or traumatic events that affect children and have a lasting impact on health and well-being. This measure is defined as the percentage of children aged 0 to 17 who experienced two or more of nine types of adverse childhood experiences.
- Concentrated Disadvantage is a life course indicator used to measure community well-being. Living in communities of concentrated disadvantage can be harmful to children through poorer quality schools; exposure to concentrated environmental hazards such as lead; lack of safe outdoor recreational spaces; exposure to adverse childhood experiences such as violence; and reduced economic mobility. The measure is calculated using five census variables: percentage below poverty line, receiving public assistance, female-headed households, unemployed and younger than age 18. It is presented as the percentage of households located in census tracts with a high level of concentrated disadvantage.
- Severe Housing Problems captures both the quality of housing through the lack of kitchen or plumbing as well as the affordability and availability of housing through cost-burden and overcrowding. Inadequate housing conditions can compromise both physical and mental health and cause or aggravate respiratory conditions and chronic disease.
- Voter Registration represents one element of social engagement. Active social engagement is associated with better health and health outcomes. This measure is defined as the percentage of U.S. citizens aged 18 and older registered to vote in biennial national elections.
2017 Annual Report Core measures added in 2017:
- Mental Health Providers was added to the clinical care category of the model to broaden the definition of clinical care to include mental health care in addition to primary care and dental care. Mental Health Providers is defined as the number of psychiatrists, psychologists, licensed clinical social workers, counselors, marriage and family therapists, providers that treat alcohol and other drug abuse, and advanced practice nurses specializing in mental health care per 100,000 population. With the addition of this measure to the model, the clinical care category weight was redistributed equally between the five clinical care measures. The addition of this measure did not appreciably effect on the overall rankings.
Supplemental measures added in 2017:
- Disconnected Youth was added as a supplemental community & environment measure. It is defined as the percentage of teens and young adults aged 16 to 24 who are neither working nor in school.
- Neighborhood Amenities was added as a supplemental community & environment measure to represent the built environment. It is defined as the percentage of children aged 0 to 17 with access to parks or playgrounds, recreation or community centers, libraries or book mobiles, and sidewalks or walking paths.
- Dedicated Health Care Provider was added as a supplemental clinical care measure. It is defined as the percentage of adults who reported having one or more people they think of as their personal doctor or health care provider.
- Six+ Teeth Extractions was added as a supplemental measure to capture oral health outcomes. It is defined as the percentage of adults aged 45 to 64 who reported having six or more teeth extracted.
Other measure changes:
- Lack of insurance was renamed Uninsured. The definition and data source remain the same.
- Public Health Funding: This year, rather than an average of the 50 states and the District of Columbia as was presented in previous editions, the U.S. average was calculated using the U.S. total for each of the three funding categories included in the numerator.
Immunizations-Adolescents, HPV Females & HPV Males: The Advisory Committee on Immunization Practices released updated human papillomavirus (HPV) vaccination recommendations in December 2016. A new two-dose schedule is recommended for females and males who initiate the vaccination series between ages 9 and 14. Three doses are still recommended for those who initiate the vaccination series at ages 15 through 26 and for immunocompromised persons. Based on the new recommendations, the HPV immunization measures are now defined as the percentage of adolescents aged 13 to 17 who are up to date on all recommended doses of HPV vaccine. The previous definition was based on the initial three-dose series recommendation.
2016 Annual Report Core measures replaced or amended:
- Poor Mental Health Days and Poor Physical Health Days in the outcome category were replaced by Frequent Mental Distress and Frequent Physical Distress, respectively. The new measures capture the percentage of adults with severe and/or chronic mental or physical health issues and align with County Health Rankings. Frequent distress is intended to measure the percentage of adults in frequent poor health (14 or more days in the past 30 days), whereas poor health days reflect the average number of poor health days in the past 30 days. Poor Mental Health Days and Poor Physical Health Days data will continue to be updated and presented as supplemental measures to provide continuity of data.
- The definition of Primary Care Physicians was amended. The new definition is limited to active physicians, and includes those in general practice, family practice, obstetrics and gynecology (OB-GYN), pediatrics, geriatrics and internal medicine. The previous definition included total physicians in general practice, family practice, OB-GYN, pediatrics and internal medicine. The measure now aligns with County Health Rankings. Data were obtained from Redi-Data Inc, a licensed provider of American Medical Association (AMA). In prior years, data were obtained from the annually printed AMA now discontinued publication Physician Characteristics and Distribution in the U.S..
- The calculation for Air Pollution was adjusted to correct an error for estimating average emissions in counties without monitors. The previous measure overstated air pollution in each state by 0.1 to 0.2 micrograms of fine particles per cubic meter.
These substitutions and adjustments did not have an appreciable effect on a state’s score or rank. Supplemental measures added:
- Colorectal Cancer Screening: Colorectal cancer is the third most commonly diagnosed cancer and the third-leading cause of cancer mortality in the United States. Colorectal cancer is easier to treat when detected early through screening. Screening also allows for removal of colorectal polyps before they become cancerous. Colorectal cancer screening is an indicator of preventive care and is an important part of clinical care targeted at early diagnosis and treatment of disease.
- Seat Belt Use: Seat belt use reduces the severity of injuries from motor vehicle accidents and reduces motor vehicle deaths. Young adults, adults living in rural areas, and men are less likely to wear seat belts. Seat belt use varies greatly by state.
- Water Fluoridation: Community water fluoridation is an effective way of preventing dental caries--an infectious disease in which bacteria dissolve tooth enamel. Water fluoridation is considered a top 10 achievement in public health in the last century. This measure was added as an indicator for implementation of this proven public health policy.
2015 Annual Report Core measures replaced or amended:
- Excessive Drinking replaced Binge Drinking as a core measure, and Chronic Drinking was added as a supplemental measure. Binge Drinking and Chronic Drinking are now separate supplemental measures. Adding Excessive Drinking allows for discussion of the health risks posed by the frequency of drinking and the amount of alcohol consumed. The definition of Excessive Drinking includes both binge and chronic drinking. Using the Excessive Drinking measure aligns with County Health Rankings.
- The definition of High School Graduation was revised. The National Center for Education Statistics (NCES) and all states have adopted the Adjusted Cohort Graduation Rate (ACGR) as the definitive measure of high school graduation. This measure is now preferred over the Average Freshman Graduation Rate (AFGR) for the following reasons:
- The ACGR employs student-level data collected over a 5-year period and accounts for movement in and out of a cohort of students due to the transfer or death of students.
- The AFGR, on the other hand, is a proxy rate indicator that is based on data available to NCES at the federal level (grade level aggregates by race/ethnicity and sex) and is a less comparable measure between states.
- The ACGR has been the standard for measuring graduation rates since 2011.
- The definition of Immunizations — Adolescents was revised. The National Immunization Survey doesn’t release a composite adolescent immunization coverage estimate as it does for the measure Immunizations — Children. When Immunizations — Adolescents was introduced in the 2013 America’s Health Rankings®, a composite value was calculated by averaging the percentage of adolescents aged 13 to 17 who received 1 dose of tetanus, diphtheria, and acellular pertussis (Tdap) vaccine since the age of 10 years; 1 dose of meningococcal conjugate vaccine (MCV4); and females who received 3 doses of human papillomavirus (HPV) vaccine. However, because HPV immunization coverage estimates are much lower than Tdap coverage estimates, this method of combination misrepresents the percentage of teens who are fully vaccinated. To address this issue, we included coverage estimates for the 3 individual vaccines to highlight the differences in coverage by vaccine. In addition, this year data became available for male HPV immunization coverage in all states except Mississippi. We averaged the female and male z scores to create a composite HPV vaccine coverage score. The Immunization — Adolescents measure was calculated as the average of the z scores for Tdap, MCV4, and combined HPV (female and male). The model weight for Immunizations — Adolescents (2.5%) is equally divided among the Tdap vaccine, meningococcal vaccine, and HPV vaccine (composite of female and male coverage estimates).
Supplemental measures added:
- Injury Deaths was added as a supplemental measure. Injuries, both unintentional and intentional, are a leading cause of morbidity and mortality in the United States.
2021 Senior Report
The new model includes 49 measures from 22 data sources. Data for nine measures are the same as appeared in the Senior Data 2020 Update. For a list of current measures, definitions and source details, see the Measures Table. The measures are grouped by model category and topic areas such as economic resources, preventive clinical services and physical health.
- College graduate
- Early death racial disparity
- Fruit and vegetable consumption
- High-speed internet
- Poverty racial disparity
- Rural population
- Fruit consumption
- Shingles vaccination
- Vegetable consumption
Measure Methodology or Name Changes
- Geriatric providers. The definition was expanded to include nurse practitioners.
- Severe housing problems. The new measure is limited to adults in one- or two-person households with an adult ages 62 and older.
- Suicide. The definition is now calculated as a crude rate rather than an age-adjusted rate.
- Voter participation (congressional). The name was changed from voter turnout — ages 65+.
Model Topic and Measure Assignment Changes Behaviors
- Sleep health. This is a new topic.
- Substance use. This is a retired topic. Measures were relocated to tobacco use or behavioral health topics.
- Tobacco use. This is a new topic. Health Outcomes
- Behavioral health. This is a new topic.
- Health status. This topic was retired; measures were relocated to behavioral health or physical health topics.
- Injury and illness. This topic was retired; measures were relocated to behavioral health or physical health topics.
- Physical health. This is a new topic. Social and Economic Factors
- Community and family safety. This new topic contains a single measure — violent crime.
- Economic resources. Previously referred to as household economics.
- Education. This new topic includes a single measure — college graduate among adults ages 65 and older.
2020 Senior Data Update
This year’s data release introduces a new model that expands the influence of social determinants of health. The policy category was dropped from the model and the community & environment category was replaced with two categories: social & economic factors and physical environment. Many measures from the prior model were retained and reassigned to a new model category. For a list of this year’s measures, definitions and source details, visit the Measures Table. The new model includes 44 measures from 20 data sources. Also new this year are 12 composite measures that represent health topics such as household economics, substance use and health status.
Retired measures Fifteen measures were dropped: • Arthritis management • Dental visit • Diabetes management • Geriatrician shortfall (replaced by a per capita measure of geriatricians) • Health care associated infection policies • Hip fractures • Home-delivered meals (available as a subgroup of community support expenditure) • Hospital deaths • ICU use • Prescription drug coverage • Education* • Overuse-Mammography* • Overuse-PSA test* • Poor mental health days* • Depression*
New measures Nineteen measures were added: • Air Pollution • Avoided care due to cost • Drinking water violations • Drug deaths (ages 65-74)* • Exercise • Frequent physical distress • Fruit consumption • Geriatricians • Insufficient sleep • Multiple chronic conditions (4+) • Non-smoking regulation • Pneumonia vaccination • Risk of social isolation • Severe housing problems • Shingles vaccination • Suicide • Vegetable consumption • Violent crime • Voter turnout
* Supplemental measures.
Eight measures were moved to a new model category:
- Community support expenditure, food insecurity, low-care nursing home residents, poverty, SNAP reach and volunteerism moved to social & economic factors.
- Obesity moved to health outcomes.
- Nursing home quality moved to clinical care.
Measures with revised definitions:
- Community support expenditure is defined as the dollars captured by the Administration on Aging per adult ages 60 and older. The measure was previously calculated per adult ages 60 and older living in poverty.
- Home health care workers’ denominator is defined as the number of personal care and home health aides per 1,000 adults ages 65 and older with a disability. The measure was previously calculated per 1,000 adults ages 75 and older.
- Suicide is defined as the number of deaths due to intentional self-harm per 100,000 adults ages 65 and older. Suicide is calculated using three years of data in order to have a sufficient sample size across all states. Suicide had been a supplemental measure presented as a single-year estimate.
Measure source changes
All measures previously accessed from the Dartmouth Atlas of Health Care were dropped or replaced by a similar measure from a different source.
- The new source for hospice care is the National Hospice and Palliative Care Organization’s NHPCO Facts and Figures report.
- The new source for hospital readmissions and preventable hospitalizations is the Office of Minority Health’s Mapping Medicare Disparities (MMD) Tool.
Measure name changes
- Community support was renamed community support expenditure.
- Health screenings was renamed cancer screenings.
2019 Senior Report The report includes 34 core measures of health that are used to rank states, and 11 supplemental measures used to highlight current and emerging issues. The 11 core measures below were not updated due to lack of data availability; their values and ranks in this edition are the same as in the 2018 edition.
- Dental visits
- Geriatrician shortfall
- HAI policies
- Prescription drug coverage
- Diabetes management
- Health screenings
- Hospital readmissions
- Preventable hospitalizations
- Hip fractures
- Teeth extractions
The following changes were made to the 2019 Edition:
- Arthritis management, previously pain management, was renamed because it is restricted to pain management among seniors with arthritis and does not assess pain management in general.
- Home-delivered meals has a change in units of measure, switching from number of home-delivered meals per 100 to percentage of population receiving home-delivered meals. This change has no impact on comparing data to previous years.
- Volunteerism is not comparable to prior editions due to a data source-methodology change.
- The Supplemental Nutrition Assistance Program (SNAP) reach numerator was revised, switching from the number of households to the number of adults participating in SNAP. Published participation rates were capped at 100, but scores and overall ranks were calculated from the original rates. SNAP reach data for previous years were updated and replaced on the website to allow for comparability.
- Avoided care due to cost, a new clinical care supplemental measure, reflects affordability of health care services and resulting unmet medical needs among seniors. Avoided care due to cost is the percentage of adults aged 65 and older who reported a time in the past 12 months when they needed to see a doctor but could not because of cost.
- Geriatricians, a new clinical care supplemental measure, captures the number of physicians specially trained to meet the unique needs of older adults. This measure is defined as the number of family medicine and internal medicine geriatricians per 100,000 adults aged 65 and older.
- Suicide, a supplemental measure, was changed from a three- to a one-year estimate. Values from previous years were updated on the website for comparability. For all editions, estimates were also calculated for age and gender subpopulations.
Overall state rankings from 2013 to 2018 have been recalculated and updated on the website to account for changes in data availability and a recalculation of arthritis management (previously pain management) in editions 2013 to 2017.
- Arthritis management. Values and rankings have been updated in editions 2013 to 2017.
- Home-delivered meals and community support. There is a two-year gap between the data year and edition year rather than a three-year gap.
- Health screening. Values and rankings for editions 2013 to 2015 were recalculated to match the current definition.
- Early death. The 2013 and 2014 values and rankings were updated with 2011 and 2012 data. Previously, both editions used 2010 data.
- SNAP reach. Values and rankings for editions 2015 to 2018 were recalculated to match the current definition.
2018 Senior Report The measures and model for America’s Health Rankings Senior Report were developed by an advisory group consisting of experts in the fields of aging and senior health for the inaugural edition in 2013. The advisory group was charged with identifying the areas of health and well-being most pertinent to the older adult population and developing a model for assessing population health at the state level. Each year, the advisory group reviews the model and measures to improve existing measures, to integrate new data sources and to adjust changing availability of information. In addition to the changes implemented in this edition, we continue to explore new data sources that could enhance our model of senior health. In particular, we are interested in state-level data for topics such as social support, polypharmacy and medication adherence, elder abuse, transportation support and malnutrition diagnosis.
The following changes were made to the 2018 Edition:
No core measures were added, dropped or revised for this edition. A new supplemental measure was added at the recommendation of the advisory group, risk of social isolation. The definition, construct and results are shown in the Senior Report Spotlight.
Due to data availability, we were unable to update the following core and supplemental measures prior to publication. The data appearing in this edition are a repeat of what appeared in the 2017 edition:
- Geriatrician Shortfall
- Health Care Associated Infection (HAI) Policies
- Hospice Care
- Hospital Deaths
- Low-care Nursing Home Residents
- Multiple Chronic Conditions
- Overuse - Mammography
- Overuse - PSA Test
- Pain Management
- Prescription Drug Coverage
Two measures were renamed to improve clarity; prior reports referred to early death as premature death and cognitive difficulty as cognition. The unit of measure was changed to improve clarity of two measures, SNAP reach and home-delivered meals. The new unit of measure is number per 100 rather than percentage, and has no impact on the ability to compare data to previous years.
2017 Senior Report The following changes were made to the 2017 Edition:
- Underweight was dropped. While malnutrition and undernourishment are serious issues among seniors, underweight is not a major health concern. Being underweight is not an automatic indication of poor health; some adults are underweight and healthy. A better way to address malnutrition would be with a malnutrition diagnosis measure or a measure that focuses on adequate and balanced nutrition. Other measures in this report that focus on nutrition and food access are food insecurity, home-delivered meals and Supplemental Nutrition Assistance Program reach. Although underweight was dropped from the model, it is available as a supplemental measure. With the removal of this measure from the model, the behaviors category weight was redistributed equally among the remaining behaviors measures.
- Recommended Hospital Care was dropped. The percentage of hospitalized adults aged 65 years and older receiving recommended hospital care ranged from 95.5% in Mississippi to 98.7% in Maine in the 2016 edition. This small geographic variation fails to distinguish any meaningful differences among states. With the removal of this measure from the model, the clinical care category weight was redistributed equally among the remaining clinical care measures.
- Healthcare-associated Infection (HAI) Policies was added. HAI policies is the percentage of 24 reporting and validation policies implemented in each state to monitor healthcare-associated infections in hospitals. With the addition of this measure to the model, the policy category weight was redistributed equally among the five policy measures.
- Nursing Home Quality was revised. The definition of nursing home quality reported in the 2016 edition used a one-month snapshot of time to capture quality. Substantial changes can occur on a month-to-month basis and a one-month snapshot may misrepresent states, especially those with few nursing homes that dominate the market. For example, if a nursing home with many beds moved in or out of the four- or five-star group for the month in which the state data was extracted, it could dramatically change the state’s value. To reduce the volatility of this measure, the 2017 edition definition used a three-month average. The new definition approximates the old definition, but is not directly comparable.
- Home-delivered Meals was revised. The denominator used in the 2016 edition definition of home-delivered meals was the total number of seniors aged 65 years and older living in poverty. It was revised in the 2017 edition to adults aged 60 years and older with independent living difficulty. This denominator better reflects the program objective of keeping seniors with independent living difficulties in their homes regardless of income. The numerator will remain the same, the number of seniors aged 60 years and older served an Older Americans Act-funded meal. The 2017 edition home-delivered meals data are not comparable to previous years.
- Health Screenings was refined. The method of calculating health screenings was refined to better account for the slight difference in age recommendations between colorectal cancer screening and mammography screening. To allow for comparability, health screenings data for all prior editions were adjusted using the new method. Health screenings is a composite measure that captures the percentage of women who reported receiving a mammogram within the past two years (aged 65 to 74 years) and the recommended colorectal cancer screening within the recommended time frame (aged 65 to 75 years), and the percentage of men aged 65 to 75 years who reported receiving the recommended colorectal cancer screening within the recommended time frame.
2016 Senior Report The following changes were made to the 2016 Edition:
- Replaced Chronic Drinking with Excessive Drinking—a combined chronic drinking and binge drinking measure.
- Replaced Poor Mental Health Days with Frequent Mental Distress.
- Added Clinical Overuse—PSA among men aged 75 and older and Clinical Overuse—Mammography among women aged 75 and older, supplemental clinical care measures, as proxies for overuse of clinical care services.
- The supplemental measure Prescription Drug Plans with a Gap was no longer available and was removed.
- The American Community Survey discontinued 3-year estimates. The measures Poverty and Able-bodied, as well as the denominators for Home-Delivered Meals, Community Support, and SNAP reach, are now based on a single year of data.
Health of Women and Children Report
2021 Health of Women and Children Report
Each year the America’s Health Rankings Health of Women and Children model is evaluated to reflect the evolving understanding of population health, integrate new data sources and adjust to changing availability of information. Final recommendations are made to the Advisory Committee. If you have measure or data source suggestions for America’s Health Rankings, please contact us at www.AmericasHealthRankings.org/about/page/submit-an-inquiry. In addition, we continue to explore other indicators that reflect health, with special attention to climate change, built environment and health equity.
The 2021 report includes 118 individual measures developed from 35 data sources. Data for 11 measures are the same as appeared in the Health of Women and Children Data 2020 Update. For a list of current measures, definitions and source details, see the Women’s Measures and Children’s Measures tables. The measures are grouped by model category and within categories by topic areas such as economic resources, preventive clinical services and physical health.
Changes Implemented in 2021
This year we replaced or amended the following measures:
- The children in poverty racial disparity measure was expanded to include all race and ethnicity groups. The original measure compared Black children to white children. The new measure compares the race/ethnicity with the highest percentage of children in poverty (which varied by state) to the percentage of non-Hispanic white children in poverty.
- The source population for the illicit drug use measure was changed from females ages 12 and older to females ages 18-49.
- The mPINC measure was renamed maternity practices score.
- The residential segregation measure was updated to reflect non-Hispanic white race groups (vs. white, including Hispanic or Latino) and to reflect household-level (vs. population-level) data.
- The data source for risk-screening environmental indicator score revised their data. As a result we updated the 2018 data, presented in the last edition, to reflect this change.
- The measure of voter participation previously reflected the midterm election. This year, with the release of 2020 presidential data, the measure was updated to represent an average of the past two national elections (a combination of midterm and presidential).
This year we introduced two new measures (not included in the composite measures):
- Breastfeeding initiation is the percentage of infants who were breastfed during the period between birth and discharge from the hospital. Source: CDC WONDER Natality Public Use Files, 2019.
- Infant child care cost is the average cost for center-based infant care as a percentage of married couple's median income. Source: The U.S. and the High Price of Child Care, 2019.
2020 Health of Women and Children Data Update
This year’s data release introduces a new model that expands the influence of social determinants of health. The policy category was dropped from the model and the community & environment category was replaced with two categories: social & economic factors and physical environment. Many measures from the prior model were retained and reassigned to new model categories. For a list of this year’s measures, definitions and source details, see the measures tables for women and children. The new model includes a total of 131 measures — 84 ranked measures and 47 supplemental measures — from 35 data sources. Also new this year are 31 composite measures that represent health topics such as economic resources, access to care and behavioral health.
New measures in the 2020 model ADD/ADHD treatment Adequate insurance - children Adequate prenatal care Adequate sleep - children Air pollution Alcohol use-youth Anxiety - children Asthma - children Avoided care due to cost - women Children in poverty Children in poverty racial gap College graduate - women Depression-children Drinking water violations Drive alone to work Early childhood education enrollment Exercise-women Flourishing - children Food sufficiency - children Foster care instability Fourth grade reading proficiency Frequent mental distress - women Frequent physical distress - women Fruit and veggie consumption-women High blood pressure - women High risk HIV behaviors - women High school graduation racial gap High-speed internet-children HPV vaccination Housing with lead risk Illicit drug use (excluding marijuana) - women Illicit drug use (including marijuana) - youth Insufficient sleep - women Low birthweight racial gap Mortality rate - women Multiple chronic conditions - women Pediatricians Physical activity - children Poverty-women Preventive dental care - children Reading, singing or storytelling Residential segregation Risk-screening environmental indicators score Severe housing problems Students experiencing homelessness Unemployment - women Uninsured children Violent crime Voter participation (midterm) Well-child visit WIC coverage Women’s health providers
New supplemental measures Arthritis-women Asthma-women Cancer (not skin) - women Child victimization Chronic kidney disease - women Chronic obstructive pulmonary disease (COPD) - women Cardiovascular disease - women Climate change and energy policies Contraceptive nonuse - youth Depression-women (part of multiple chronic conditions) Diabetes-women (part of multiple chronic conditions) E-cigarette use-women Electronic vapor product use - children Gender pay gap High health status - women High health status - children Intimate partner violence before pregnancy Maternal morbidity Soda consumption - youth Transportation and energy use Demographic: % of children with special health care needs Demographic: % children (<18) Demographic: % infants Demographic: % women ages 18-44
Retired measures Adequate health insurance Adolescent well-visit Baby-friendly facility Children with health insurance Homeless family households HPV immunization females HPV immunization males Intimate partner violence - lifetime Infant child care cost Medical home for child with special health care needs Meningococcal immunizations Missed school days Prenatal care before third trimester Preterm birth Protective family routines and habits Substance use disorder-children Supportive neighborhoods Tdap immunizations Well-baby check Alcohol use before pregnancy Detracted neighborhood elements Intimate Partner Violence-Pregnancy Mental health care-children
Retired supplemental measures Alcohol use before pregnancy Detracting neighborhood elements Intimate partner violence - pregnancy Mental health care - children Socioeconomic hardship, previously a component of adverse childhood experiences
Measures reassigned to a new model category or population group Behaviors to health outcomes
- Excessive drinking
- Overweight or obesity
Behaviors to social and economic factors
- High school graduation
Community & environment to social and economic factors
- Adverse childhood experiences
- Neighborhood amenities
- Concentrated disadvantage
- Food insecurity - household
Community & environment to physical environment
- Household Smoke
Policy to clinical care
- Childhood immunizations
- Postpartum visit
- Publicly-funded women’s health services
- Uninsured women
- Policy to Physical Environment
- Water fluoridation
Health outcomes to behaviors
- Teen births
- Unintended pregnancy
- Diabetes-women (subpopulation of Multiple chronic conditions)
- Drug deaths-women
- Maternal mortality
- Neonatal mortality
- Teen suicide
Infants to women
- Low-risk cesarean delivery
- Smoking during pregnancy
Infants to children
- Infant mortality
- Low birthweight
- Sleep position
Adverse childhood experiences: Previously reported as two or more of nine adverse experiences, the new measure is two or more of eight adverse experiences.
Childhood immunizations: This measure is not comparable to prior years due to an improved methodology implemented by the data source.
Developmental screening: Previously a general measure of screening among children ages 0-5, the new measure is a more specific measure of children ages 9-35 months.
Maternal mortality: calculated using the revised methodology provided by the National Center for Health Statistics.
Medical home: Expanded from children with special health care needs to all children.
mPINC: This measure is not comparable to prior years due to an improved methodology implemented by the data source.
Tobacco use - youth: The new measure is calculated from the public use data file rather than estimates provided in published state tables.
Water fluoridation: This measure is not comparable to prior years due to an improved methodology implemented by the data source.
Measure name changes Smoking during pregnancy (was tobacco use during pregnancy) HPV vaccination (was HPV immunization)
No data update since 2019 edition Breastfed: Data appearing in the 2020 update are the same that appeared in the 2019 edition.
2019 Health of Women and Children Report The following changes were made to the 2019 Edition:
State Rankings Measures
Fifty-five measures are used to rank states. Seven of the measures (listed below) were not updated due to lack of data availability; the values and ranks of these seven measures are the same this year as in the 2018 edition.
- Cervical cancer screening
- Dental visit
- Intimate partner violence - Lifetime
- Publicly-funded women’s health services
- Protective family routines and habits (Ages 0-17)
- Water fluoridation
Women Uninsured, previously defined as women ages 18-44, is now defined as women ages 19-44 due to a change by the source.
Maternal mortality, previously defined as deaths in the 42 days after delivery, is now defined as deaths in the year following delivery.
Unintended pregnancy replaces intended pregnancy. Data are missing for several states, so this measure is not included in the state rankings calculation.
Infants Drinking before pregnancy replaces alcohol consumption during pregnancy. Data are missing from several states, so this measure is not included in the state rankings calculation.
Children Child mortality, previously defined as children ages 1-18, is now defined as children ages 1-19. Homeless family households is not comparable to prior editions due to a methodology change by the data source.
National Survey of Children’s Health measures were adjusted from one-year to two-year estimates to improve state-level sample size.
Twelve supplemental measures were added to the report this year. These measures are not included in the state rankings calculation. They are intended to highlight current and emerging issues affecting women and children.
- Air pollution
- Asthma - Children
- Children in poverty
- Detracting neighborhood elements
- Flourishing (Ages 0-5)
- Flourishing (Ages 6 -17)
- Frequent mental distress - Women
- Housing with lead risk
- Mental health care - Children
- Preventive dental care - Children
- Severe housing problems
- Students experiencing homelessness
See the Supplemental Measures table for current definitions and source details. To explore the measures visit AmericasHealthRankings.org/explore/health-of-women-and-children.
2018 Health of Women and Children Report The following changes were made to the 2018 Edition:
Many measures in the 2018 edition are not comparable to the 2016 edition because of changes in the methodology of the source or a change in definition of the measure.
One key data source, the National Survey of Children’s Health (NSCH), changed their methodology and it affected these measures:
- Adequate health insurance
- Adverse childhood experiences
- Adolescent well-visit
- Children with health insurance
- Developmental screening
- Household smoke
- Medical home for child with special health care needs
- Missed school days
- Neighborhood amenities
- Overweight or Obese
- Supportive neighborhoods
- Well-baby check
In addition, there were two protective home environment measures from NSCH in the 2016 edition, one for children age 0 to 5 and one for children aged 6 to 17. The 2018 edition collapsed these two measures into one titled protective family routines and habits, aged 0 to 17. We do report subpopulations by age for this measure, aged 0 to 5, aged 6 to 11 and aged 12 to 17 in the supplemental measures section. Home health visit was dropped in 2018 because the measure was eliminated from the NSCH, as well as the Pregnancy Risk Assessment Monitoring System (PRAMS), an alternative data source.
Human papillomavirus (HPV) immunizations for both males and females were updated to reflect the new recommendations from the Advisory Committee on Immunization Practices (ACIP). Accordingly, the summation measure, immunization - Adolescents, cannot be compared directly between editions.
The source for alcohol during pregnancy was changed from BRFSS to PRAMS in 2018. PRAMS data provides a more accurate and reliable estimate since PRAMS samples women who have had a recent birth and asks specifically about alcohol consumption during pregnancy. The revised measure now focuses on alcohol consumption during the last three months of pregnancy.
Unintended pregnancy from Guttmacher Institute was replaced with intended pregnancy from PRAMS. It was reframed to better align with the question being asked of respondents.
Smoking during pregnancy from BRFSS was updated to tobacco use during pregnancy from National Vital Statistics System (NVSS) birth certificate data. It provides a broader picture of tobacco use and a more precise data source.
Substance use disorder, formerly drug dependence or abuse, was updated to reflect methodology changes from the National Survey of Drug Use and Health.
The data for breastfed are from the National Immunization Survey (NIS). The data used in the 2016 edition were as reported in the CDC Breastfeeding Report Card. The NIS data are now available directly through an online portal hosted by the Division of Nutrition, Physical Activity and Obesity. The 2016 edition breastfed measure was updated this year to reflect a more current data year.
Intimate partner violence - lifetime was changed from a one-year estimate in the 2016 edition to a three-year estimate in 2018. The definition is also slightly different and cannot be compared with the 2016 edition. 2016 Health of Women and Children Report The following changes were made to the 2016 Edition:
The model and measures for the America’s Health Rankings® Health of Women and Children Report were developed by an advisory steering group of experts in the field of maternal and child health. The panel was charged with developing a model for assessing the health of women and children at the state level.
The steering group convened over a series of meetings to establish the broad categories to include in the model. Life course theory was layered on top of America’s Health Rankings® five component model of population health. This produced a three-tiered scorecard. The three tiers describe the behaviors, community & environment, policy, clinical care, and outcomes for 1) women of reproductive age, 2) infants, and 3) children using 64 different health measures.
Concurrently with meetings, a series of surveys were sent to steering group members to identify specific determinant measures and outcome measures to be included in the model and to narrow down the list of possible measures. The weighting of each category within the model was similarly discussed and agreed upon by the steering group.
Health of Those Who Have Served Report
2016 was the inaugural edition of this report.
Health of Women Who Have Served Report
2017 was the inaugural edition of this report.