Determinants

Personal Behaviors

Four determinants reflect personal behaviors and their impact on health: the prevalence of smoking, the motor vehicle death rate, the prevalence of obesity and the high school graduation rate.  These determinants measure both positive and negative behaviors and activities that have 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 personal behaviors that need to be addressed in a comprehensive public health effort.  For example, the American Academy of Family Physicians suggests that to improve their 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, and
• See a doctor regularly for preventive care.

Additional suggestions for individual initiatives are in Healthy People in Healthy Communities, A Community Planning Guide Using Healthy People 2010, published by the U.S. Department of Health and Human Services, Washington, D.C., available at http://www.healthypeople.gov/Publications/HealthyCommunities2001/default.htm. 

Prevalence of Smoking measures the percent of the population over age 18 that smokes tobacco products regularly.  The information is obtained from the Behavioral Risk Factor Surveillance System (BRFSS) and measures the percentage of the population that has smoked at least 100 cigarettes and currently smokes regularly.  

The prevalence of smoking in the population has an adverse impact on overall health by causing increased cases of respiratory diseases, cancer and other illnesses.  It is a lifestyle behavior that an individual can directly influence. 

Table 20 displays the 2006 ranks, based on 2005 data (Behavioral Risk Factor Surveillance System, Centers for Disease Control and Prevention).  The national average is 20.6 percent of the population, a decrease of 0.2 percent from the rate last year. This means that over 45 million American adults smoke on a regular basis. The proportion of the population that smokes varies from a low of 11.5 percent in Utah to more than 25 percent in Kentucky, Indiana, West Virginia, Tennessee and Oklahoma.  The prevalence of smoking decreased by 2.0 percent or more in Delaware, Ohio, Illinois, Arkansas and Kansas.  It increased by more than 2.0 percent in Georgia and Indiana.  If all states were to accomplish a smoking rate equal to the best state (Utah), there would be 20 million less smokers in the U.S.

Since the 1990 Edition, the prevalence of smoking decreased in the United States by 8.9 percent.  Rhode Island, Connecticut, Nevada, Kansas, Virginia and Michigan each lowered the prevalence of smoking since 1990 by 12 percent or more.  Every state experienced a decrease since the 1990 Edition.  Utah and Nebraska had the smallest decreases. Due to the limits of the BRFSS, caution must be used in comparing changes in prevalence of smoking in states with small populations.

Go to Prevalence of Smoking Page

Motor Vehicle Deaths measures the annual number of deaths per 100,000,000 miles driven and is compiled by the National Safety Council.  Motor vehicle deaths reflect reckless driving and the effects of excessive use of alcohol and drugs on the general population.  This component is not adjusted for the quality of each state’s road system, law enforcement, vehicle inspections, weather or drivers’ ages.

Table 21 displays the 2006 ranks, based on 2005 data (National Safety Council, Itasca, Ill.).  Motor vehicle death rates vary from less than 1.0 deaths per 100,000,000 miles driven in Vermont (estimated), Massachusetts and Connecticut to a high of 2.4 deaths per 100,000,000 miles driven in Mississippi.  The national average is 1.5 deaths per 100,000,000 miles driven, unchanged from the 2005 Edition.  Alaska, Arkansas and New Mexico show the largest decreases in this area since the 2005 Edition with decreases of 0.3 to 0.6 deaths per 100,000,000 miles driven, while North Dakota shows an increase of 0.3 deaths per 100,000,000 miles driven.  Since the 1990 Edition, motor vehicle death rates overall decreased by 1.0 deaths per 100,000,000 miles driven, with both Vermont and Oregon showing the greatest decreases of 1.7 and 1.6 deaths per 100,000,000 miles driven, respectively.  All states have improved since 1990.

Go to Motor Vehicle Deaths Page

Prevalence of Obesity is the percentage of the population estimated to be obese, defined as having a body mass index (BMI) of 30.0 or higher. BMI 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 and determines weight status per Table 13.  Obesity is known to contribute to a variety of diseases, including heart disease, diabetes and general poor health. The data are collected by each state as part of the Behavioral Risk Factor Surveillance System of the Centers for Disease Control and Prevention.

Table 13 - Body Mass Index (BMI)

Table 22 displays the 2006 ranks, based on 2005 data (Behavioral Risk Factor Surveillance System, Centers for Disease Control and Prevention).  The average for the United States is 24.4 percent of the adult population, up from 23.1 percent of the population in 2005 and double the rate of 11.6 percent of the population in 1990. In the United States, this means that over 53 million adults are obese, that is they have 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 over 25 million fewer obese individuals.

The prevalence of obesity ranges from 17.8 percent of the population in Colorado to over 30 percent of the population in Mississippi, Louisiana and West Virginia.  In the last year, only Hawaii, Ohio and Maine experienced a decline in the prevalence of obesity but each is only a slight decline.  In South Carolina, Louisiana, Alaska, Idaho, Wyoming and West Virginia, the prevalence of obesity in their populations increased by 3 percent or more.  Since 1990, the prevalence of obesity increased in all states.  It increased the least in Connecticut, Nevada, Delaware and Florida, where an additional one of 11 people are now obese. It increased the most in Louisiana, where an additional one of six people is now obese.

Go to Prevalence of Obesity Page

High School Graduation estimates the percentage of students who graduate within four years and are considered regular graduates.  The National Center for Education Statistics collects the enrollment and completion data and, now, as part of the No Child Left Behind initiatives, 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 average freshman enrollment count is the sum of the number of 8^th graders five years earlier, the number of 9^th graders four years earlier (because this is when current year seniors were freshmen), and the number of 10^th graders three years earlier divided by three.  Enrollment counts include a proportional distribution of students not enrolled in a specific grade. 

From 1990 through the 2005 Edition, America’s Health Rankings™ used a different definition of high school graduation (the number of regular graduates divided by the number of 9^th graders four years prior), so direct comparison of 2005 Edition values to values published in prior editions is not valid.  In this report, data from the 2005 Edition was restated using the NCES definition to allow valid year-to-year comparisons.

Data are not adjusted for the presence or quality of basic health and consumer health education in the curriculum, for continuing education programs or 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.

Education is vital as consumers must be able to learn about, create and maintain a healthy lifestyle and, when necessary, understand their options for care.

Table 23 displays the 2006 ranks, based on 2002 to 2003 data (National Center for Education Statistics, Washington, D.C., U.S. Department of Education).  The rate varies from 87.0 percent of incoming ninth graders who graduate within four years in New Jersey to 59.7 percent in South Carolina.  The national average is 73.9 percent, higher than the reported rate for three years prior of 71.7 percent. 

Graduation rates generally declined from 1990 through early 2000.  They have now started to increase but still lag behind rates of the early 1990s.

Go to High School Graduation Page

Community Environment 

Four measures are used to represent the community environment: the violent crime rate, the percentage of children in poverty, the prevalence of infectious disease and the occupational fatalities rate.  Measures of community 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 violence, illegal drugs, infectious disease and unsafe workplaces are detrimental.  In addition, studies indicate that the general socio-economic conditions have a significant relationship to the healthiness of a community’s residents.   

These determinants measure both positive and negative aspects of the community 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 four measures.  Each community has its strengths, challenges and resources and should undertake a careful planning process to determine what action plans are best for them.  The inside back cover describes seven ways communities can take action to improve the health of the community. 

Violent Crime measures the effect of criminal behavior on a population’s health.  It represents factors such as illegal drug use and various social ills.  Violent crime measures the annual number of murders, rapes, robberies and aggravated assaults per 100,000 population.  Violent crime reflects an aspect of current U.S. lifestyle and is an indicator of health risk and death.

Table 24 displays the 2006 ranks, based on 2005 data (Crime in the United States: 2005. Washington, D.C., Federal Bureau of Investigation).   

The violent crime rate varies from a low of 98 offenses per 100,000 population in North Dakota, 112 offenses per 100,000 population in Maine and 120 offenses per 100,000 population in Vermont to a high of 761 offenses per 100,000 population in South Carolina, 753 offenses per 100,000 population in Tennessee and 708 offenses per 100,000 population in Florida.  The national average is 469 offenses per 100,000 population, up 6 offenses per 100,000 population from the revised FBI crime rate for the prior year and down 140 offenses per 100,000 population from the 1990 Edition.    

The largest reported decrease in violent crime from the 2005 Edition occurred in Louisiana where reported offenses decreased by 45 offenses per 100,000 population.  Eighteen other states experienced decreases.  The largest reported increases occurred in Delaware, from 568 to 632 offenses per 100,000 population and in Michigan, from 490 to 552 offenses per 100,000 population. 

This is the seventh year that the national violent crime rate is lower than the 1990 Edition.  However, 19 states experienced increases since 1990, led by Tennessee, Delaware and Alaska with increases of 219 offenses, 200 offenses and 177 offenses per 100,000 population, respectively.  New York, California and Florida reduced violent crime the most since the 1990 Edition, decreasing from 1,007 to 446 offenses per 100,000 population, from 918 to 526 offenses per 100,000 population, and from 1,024 to 708 offenses per 100,000 population, respectively. 

Go to the Violent Crime Page 

Occupational Fatalities represents the impact of hazardous jobs on the population.  Occupational injuries would be a preferred component; however, there is not a uniform reporting system used by all 50 states.  Due to the different industry mixes in each state, occupational fatalities are adjusted to more accurately reflect the actual safety differences between the states.  

Occupational fatalities are measured over a three-year span because of their low incidence rate.  The industry adjustment is based on the ratio of workers in the following industries: construction, manufacturing, trade, transportation, utilities, professional and business services as defined by North American Industry Classification System (NAICS).

Table 25 displays the 2006 ranks, based on 2002 to 2004 data (Census of Fatal Occupational Injuries, Bureau of Labor Statistics, U.S. Department of Labor, Washington, D.C.).  Scores vary from 2.5 deaths per 100,000 workers in Massachusetts to 10 or more deaths per 100,000 workers in Wyoming, Mississippi, Alaska, Montana, Louisiana, New Mexico, Arkansas and West Virginia.  The national norm is 4.9 deaths per 100,000 workers, up from 4.7 deaths per 100,000 workers in the 2005 Edition.  In Wyoming and Louisiana, the occupational fatalities rate increased by more than 5.0 deaths per 100,000 workers in the past year. 

Go to the Occupational Fatalities Page 

Infectious Disease includes the occurrence of Acquired Immune Deficiency Syndrome (AIDS), tuberculosis and hepatitis (all types) as representative of all major infectious diseases in a state.  It is a running three-year average. 

This component is not age- or race-adjusted.  Also, as each individual state health department reports these diseases, the level of accuracy may differ from state to state.

Table 26 displays the 2006 ranks, based on 2003 to 2005 data (Mortality and Morbidity Weekly Reports, Centers for Disease Control and Prevention).  The incidence of infectious disease per 100,000 population varies from a reported low of less than five cases in North Dakota, South Dakota, Montana and Idaho to a reported high of more than 40 cases in New York.  The national average is 22.6 cases per 100,000 population, down from 24.6 cases per 100,000 population from the 2005 Edition and down considerably from 40.7 cases per 100,000 population from the 1990 Edition. 

Reported infectious disease decreased by 4.0 or more cases per 100,000 population in Georgia, Missouri and Louisiana.  It increased in only 5 states; New Hampshire, Delaware, Maine, South Dakota and West Virginia.  Since the 1990 Edition, Alaska, Oregon and Washington have seen the greatest decreases in reported cases with more than 70 fewer cases per 100,000 population.  No states have experienced increases in the incidence of infectious disease since the 1990 Edition.

Got to the Infectious Disease Page

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 is approximately $19,970 in household income.   

Table 27 displays the 2006 ranks, based on 2005 data (March 2006 Current Population Survey, Washington, D.C., U.S. Census Bureau).  The percentage of children in poverty ranged from less than 10 percent of persons under age 18 in New Hampshire, Vermont and New Jersey to a high of more than 30 percent in Mississippi.  The national average is 17.6 percent, down 0.2 percent from the 2005 Edition and up 1.8 percent from the 2002 Edition.  It is 3.0 percent below the 1990 Edition.  In the past year, the percentage of children in poverty increased in 28 of 50 states. It increased by more than 4 percent in Mississippi, Oklahoma and Louisiana.  Children in poverty decreased by more than 4 percent in Wisconsin.  Since 1990, the percentage of children in poverty has increased in 13 of 50 states.  It increased by 5 percent or more in Oregon, Delaware and Rhode Island.  It decreased by 10 percent or more in Louisiana, Minnesota, Hawaii and Tennessee since 1990.

Go to Children in Poverty Page

Public Health Policies

Three measures are used to represent public health policies and programs: per capita public health spending, immunization coverage and lack of health insurance.  These components are indicative of the availability of resources and the extent of the program’s reach to the public.  

States have many additional 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 summary lists the Web address for that state health department.  Individuals can also see the spectrum of options available to states and communities by visiting www.thecommunityguide.org, a Web site that provides a systemic review of programs and evidence-based recommendations for health and community officials. 

Lack of Health Insurance measures the percentage of population not covered by private or public health insurance.  Individuals without health insurance have great difficulty accessing the health care system, frequently do not participate in preventive care programs and can add substantially to the cost of healthcare due to delayed or emergency-room treatment. 

Table 28 displays the 2006 ranks, based on 2005 data (March 2006 Current Population Survey, Washington, D.C., U.S. Census Bureau).  Lack of coverage ranged from less than 10 percent in Minnesota, Iowa, Hawaii, Massachusetts and Wisconsin to over 24 percent in Texas.   The national average is 15.9 percent (46.6 million people) uninsured, which is an increase of 0.2 percent from the 2005 Edition and a 2.5 percent increase since 1990.  If the United States as a whole could emulate the best state, the number of uninsured would decrease by over 20 million people or about the population of Texas.

In the last year, the percentage of uninsured population decreased in 23 states, including Massachusetts (decreased by 1.9 percent), Montana (decreased by 1.7 percent) and Kentucky (decreased by 1.6 percent).  The percentage of uninsured population increased in 26 states, including an increase of 3.1 percent in Arizona and 3.0 percent in South Carolina.

Go to Lack of Health Insurance Page

Per Capita Public Health Spending measures the dollars per person that are spent on public or population health in a state.  High spending on these 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.   

This measure includes expenditures in three categories as defined by the National Association of State Budget Officers (NASBO): 

Direct Public Health Care Services: Includes local health clinics, Ryan White AIDS Grant expenditures, and American Indian health. Expenditures may include funds spent on pharmaceutical assistance for the elderly, childhood immunization, chronic disease hospitals and programs, hearing aid assistance, adult day care for persons with Alzheimer’s disease, health grants, services for medically handicapped children, the Women, Infant, and Children (WIC) program, pregnancy outreach and counseling, chronic renal disease treatment programs, AIDS testing, breast and cervical cancer screening, tuberculosis (TB) programs, emergency health services, adult genetics programs and phenylketonuria (PKU) testing. 

Community-Based Services Health Expenditures: State funds spent on health services provided in a community setting. Examples include rehabilitation services, alcohol and drug abuse treatment, mental health community services, developmental disabilities community services, and vocational rehabilitation services. These expenditures do not include funds spent on services eligible for Medicaid reimbursement, which are reported under Medicaid. 

Population Health Expenditures: Includes programs such as AIDS and other STD control, screening, outreach, and monitoring, including data collection and registries, immunization, including the cost of vaccine and infrastructure only, infectious disease control, including analysis and monitoring, emerging infections, microbiology lab services, food and lodging licensing and inspection, food safety and inspection, fish consumption advisory, pest eradication (such as rats, roaches, and mosquitoes), and veterinary diseases affecting the food chain, such as mad cow disease. 

Table 29 displays the 2006 ranks, based on 2003 data (National Association of State Budget Officers).  It ranges from more than $400 per person in Alaska and Hawaii to less than $75 per person in Iowa, Arkansas, Idaho and Utah.  The data has not changed from the 2005 Edition.

Go to Per Capita Public Spending Page 

Immunization Coverage is the percentage of children ages 19 to 35 months who have received the suggested early childhood immunizations listed in Table 14.  Early childhood immunization has been shown to be a safe and cost-effective manner of controlling diseases within the population.

Table 14 - Immunization Coverage

Table 30 displays the 2006 ranks, based on 2005 data (National Immunization Program, Centers for Disease Control and Prevention).  It ranges from immunization coverage of more than 90 percent in Massachusetts to less than 70 percent in Nevada and Arkansas.  Compared to coverage in the prior year, coverage for the complete series of immunizations in the United States has essentially remained the same at 80.8 percent of children ages 19 to 35 months.  In the last year, coverage has increased in 24 states and has decreased in 24 states.  Coverage in Nebraska, Kansas and Colorado increased the most (more than 6 percent), while coverage in West Virginia and Arkansas decreased the most (more than 10 percent).  In the last 11 years, coverage in the United States increased from 55.1 percent to 80.8 percent of children ages 19 to 35 months who received the complete set of immunizations; however, the rate of improvement has leveled off significantly in the last three years.

Go to Immunization Coverage Page

Clinical Care

Preventive and curative care must be delivered in an effective, appropriate and timely manner.  In the 2006 Edition, only one measure is included in this section – adequacy of prenatal care.  However, two additional measures are discussed for possible inclusion in the 2007 Edition. 

Adequacy of Prenatal Care is a measure of both access to and frequency of prenatal care based on the Adequacy of Prenatal Care Utilization (APNCU) Index developed by Kotelchuck. This index considers two aspects of prenatal care: the month it was initiated and the number of visits occurring after initiation.  The 1990 through 2004 Editions of the report defined Adequacy of Prenatal Care using the Kessner Index, a measure highly correlated to Kotelchuck, however, it does not consider both initiation and frequency of visits.

Adequacy of prenatal care is not adjusted for age or race.

Table 31 displays the 2006 ranks, based on 2004 data (National Center for Health Statistics. Adequacy of Care by State, United States, Hyattsville, Md.).  Not all prenatal care numbers are comparable since the data is collected from two different forms of birth certificates.  The states, marked with asterisks, have begun using the 2003 revision to the birth certificate and can only be compared to other states with an asterisk.  All other states use the 1988 revision and are directly comparable.  The states using the 2003 revision were assigned scores and ranks based upon prior year data to avoid a lowering of their scores due to the improved data collection method. 

Access to adequate prenatal care ranges from more than 85 percent of pregnant women in New Hampshire, Maine and Vermont to less than 60 percent in New Mexico.  An increase of 2.9 percent in access to adequate prenatal care in the last year occurred in Wyoming.  Connecticut reported a decrease of 3.7 percent in the past year. 

Go to Adequacy of Prenatal Care Page