Executive SummaryIntroductionExplore the Health of Women, Children and InfantsFindingsThe Health of Women and Children between StatesThe Health of Women and Children within StatesHealthy Communities for ChildrenClinical Preventive Services for ChildrenRacial Disparities in Measures of MortalityVariations in SmokingMeasures of Women's HealthBehaviors | Measures of Women’s HealthCommunity & Environment | Measures of Women’s HealthPolicy | Measures of Women’s HealthClinical Care | Measures of Women’s HealthOutcomes | Measures of Women’s HealthMeasures of Infants' HealthBehaviors | Measures of Infants’ HealthCommunity & Environment | Measures of Infants’ HealthPolicy | Measures of Infants’ HealthClinical Care | Measures of Infants’ HealthOutcomes | Measures of Infants’ HealthMeasures of Children's HealthBehaviors | Measures of Children’s HealthCommunity & Environment | Measures of Children’s HealthPolicy | Measures of Children’s HealthClinical Care | Measures of Children’s HealthOutcomes | Measures of Children’s HealthState SummariesAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDistrict of ColumbiaUnited StatesAppendixData Sources and Measures of Women’s HealthData Sources and Measures of Infants’ HealthData Sources and Measures of Children’s HealthMethodologyModel DevelopmentAmerica’s Health Rankings® Health of Women and Children Steering GroupThe Team
For each measure, the raw data are obtained from secondary sources (Tables 6–8) and presented as a “value.” The most current data available as of July 2016 were collected. The score for each state is based on the following formula:
This “z score” indicates the number of standard deviations a state value is above or below the national value. A 0.00 indicates a state has the same value as the nation. States with higher values than the national value have a positive score; states below the national value have a negative score. To prevent an extreme score from exerting excessive influence, the maximum score for a measure is capped at +/- 2.00. If a US value is not available for a measure, the mean of all state values is used with the exception of measures from the Behavioral Risk Factor Surveillance System (BRFSS) and the Pregnancy Risk Assessment Monitoring System (PRAMS). For BRFSS measures, the median of the state values is used for the US value to conform to the Centers for Disease Control and Prevention methodology. Overall score is calculated by adding the scores of each measure multiplied by its assigned weight (the percentage of total overall ranking). For PRAMS measures, a US value was not calculated due to missing data in several states and an overall score was not calculated. Therefore, the four PRAMS measures were excluded from the rankings calculation.
Each of the five major categories of the America’s Health Rankings® model of health (behaviors, community & environment, policy, clinical care, and outcomes) are assigned an equal weight of 0.20. Each of the three population groups (women, infants, and children) are then assigned an equal weight within these categories, or 0.06666 (that is 1.0 divided by 5 categories in the model divided by 3 population groups). Subsequently, each measure within a category-population group (such as behaviors-women) is assigned an equal weight. For example, for the five measures in the behaviors-women group, the weight of each measure is 0.01333 (that is 1.0 divided by 5 categories in the model divided by 3 population groups divided by 5 measures within the group). For category-population groups in which a state’s score for a measure is missing, the weight of the remaining measures are redistributed such that the total weight for the category-population group remains the same.
The overall ranking is the ordering of each state according to the overall score. The ranking of individual measures is the ordering of each state according to the measure’s value, with the exception of immunizations-adolescents, which is ranked according to score. Ties in values are assigned equal ranks. Not all changes in rank are statistically significant.
Concentrated disadvantage was calculated using American Community Survey data from the US Census Bureau according to the method described in Life Course Indicator Tip Sheet: Concentrated Disadvantage (LC-06), and as described in Life Course Indicator: Concentrated Disadvantage, both published by the Association of Maternal and Child Health Programs. They are available at www.amchp.org. A census tract was labeled disadvantaged if it fell in the lowest 20% of census tracts in the United States. Data were aggregated to the state level by summing the population of the census tracts labeled as disadvantaged and dividing by the population of all census tracts. Census tracts for which all data were not available were excluded from the calculation.
Prenatal Care Before the Third Trimester
Data for the measure prenatal care before 3rd trimester were obtained from birth certificate data provided by the National Vital Statistics System (NVSS). The US value reflects the mean values from all of the states utilizing the NVSS 2003 US Standard Certificate of Live Birth. Mothers residing in a state that used the 1989 US Standard Certificate of Live Birth were excluded, as well as states in which 10% or more of data were missing. In addition, in several states included in the calculation the percentage of missing data for this measure was between 2–10%. Due to missing data, the calculated US value may not reflect the true US value.
Pregnancy Risk Assessment Monitoring System
The Pregnancy Risk Assessment Monitoring System (PRAMS) is a joint research project by the Centers for Disease Control and Prevention 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 on her infant are collected. PRAMS is one of the only sources for such data on a state-by-state basis.
When data were obtained for this report, the most recent PRAMS data available were from 2012. This report contains PRAMS data from only 30 states, due to lack of participation in PRAMS or low response rates in several states. Data from New York City were collected separately from the state of New York. For the purposes of this report, these data were combined to represent the state of New York. One additional state — California — collects similar data through an analogous research project, Maternal and Infant Health Assessment (MIHA), and these data were also included. Because of missing data for 19 states, only state values are reported (no US value) and values for these measures were not used to calculate rankings.
More information on PRAMS can be found at https://www.cdc.gov/prams/. More information on California’s program (MIHA) can be found at http://www.cdph.ca.gov/data/surveys/MIHA/Pages/MaternalandInfantHealthAssessment(MIHA)survey.aspx.
National Survey of Children’s Health and Behavioral Risk Factor Surveillance System
Both the National Survey for Children’s Health (NSCH) and the Behavioral Risk Factor Surveillance System (BRFSS) were analyzed using Stata 14.1 to account for the complex design of the surveys. For NSCH data, the suggested code provided in the NSCH_2-11_2012_FAQs document was used to declare the survey design. “Refused” and “don’t know” responses were set to missing and missing values were excluded from the analysis per guidelines provided for NSCH data analysis (see http://childhealthdata.org/learn/NSCH/resources). Single-imputation data were used to examine household income (relative to the federal poverty level) due to relatively high nonresponse rates for questions on household income in 2011-2012. Definitions of each measure are based upon 2011-2012 National Survey of Children’s Health: SAS Code for Data Users: Child Health Indicators and Subgroups (Version 1.0) published by the National Survey of Children’s Health and the Child and Adolescent Health Measurement Initiative, from the Data Resource Center for Child and Adolescent Health.
For NSCH race/ethnicity data, we excluded the “Other, non-Hispanic/Multi-racial” category from our analysis. This category includes non-Hispanic children reporting only one race category of Asian, American Indian, Alaska Native, Native Hawaiian, Pacific Islander, or multi-racial. Missing data for the race/ethnicity variable represents a weighted percentage of 2% of the sample.
For BRFSS data, “refused,” “don’t know,” or “not sure” responses were excluded from the analysis, but are reflected in standard error and confidence interval estimates. Not asked or missing responses were set to missing values and also excluded from the analysis.