Risk Factors

Personal Behaviors

Four components 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 components 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 components 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 lists the following as the choices individuals can make to improve their health:

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

Additional suggestions for individual initiatives are in Healthy People 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

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 18 displays the 2004 ranks, based on 2003 data (Behavioral Risk Factor Surveillance System, Centers for Disease Control and Prevention). The proportion of the population that smokes varies from a low of 11.9 percent in Utah to more than 30 percent in Kentucky. The national average is 22.0 percent of the population, a decrease of 1.0 percent from the revised rate for the past year. The prevalence of smoking decreased by more than 2.0 percent in Hawaii, Alaska, Delaware, Arizona, Virginia and Tennessee. It increased by more than 2.0 percent in Louisiana. Since the 1990 Edition, the prevalence of smoking has decreased in the United States by 7.5 percent. Rhode Island, Vermont, Connecticut, Virginia, Nevada, Hawaii, and Colorado have each lowered the prevalence of smoking since 1990 by 10 percent or more.

Every state has experienced a decrease since the 1990 Edition. Missouri, South Carolina and Utah have 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.

Motor Vehicle Deaths

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, weather or drivers' ages.

Table 19 displays the 2004 ranks, based on 2003 data (National Safety Council, Itasca, Ill.). Motor vehicle death rates vary from a low of 0.7 deaths per 100,000,000 miles driven in Vermont to a high of 2.5 deaths per 100,000,000 miles driven in Montana. The national average remains at 1.6 deaths per 100,000,000 miles driven, same as the 2003 Edition. West Virginia and Colorado show the largest decreases in this area since the 2003 Edition with decreases of 0.3 deaths per 100,000,000 miles driven, while South Dakota shows an increase of 0.4 deaths per 100,000,000 miles driven.

Since the 1990 Edition, motor vehicle death rates overall have decreased by 0.9 deaths per 100,000,000 miles driven, with Vermont and Oregon showing the greatest decreases of 1.7 deaths and 1.5 deaths per 100,000,000 miles driven, respectively.

Only Montana and South Dakota have increased since 1990, moving from 2.4 to 2.5 deaths per 100,000,000 miles driven and from 2.3 to 2.4 deaths per 100,000,000 miles driven, respectively.

Prevalence of Obesity

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.

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 20 displays the 2004 ranks, based on 2003 data (Behavioral Risk Factor Surveillance System, Centers for Disease Control and Prevention). The prevalence of obesity ranges from 16.0 percent of the population in Colorado to more than 28 percent of the population in Mississippi and Alabama. The average for the United States is 22.8 percent of the population, up from 22.1 percent of the population in 2003 and under 12 percent of the population in 1990.

In the last year, the prevalence of obesity in Virginia, Massachusetts and South Carolina decreased by more than 1 percent of the population. In Utah and California, the prevalence of obesity increased by more than 3 percent of the population. Since 1990, the prevalence of obesity has increased in all states. It has increased the least in Florida, Wyoming and Massachusetts, where an additional 1 out of 14 people are now obese. It has increased the most in Alabama and Georgia where an additional 1 out of 7 people are now obese.

High School Graduation

High School Graduation measures the percentage of ninth graders who graduate within four years and are considered regular graduates by the state. The National Center for Education Statistics annually collects the enrollment and completion data from which graduation rates are calculated. 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 21 displays the 2004 ranks, based on 2001 to 2002 data (National Center for Education Statistics, Washington, D.C., U.S. Department of Education). The rate varies from 89.8 percent of incoming ninth graders who graduate within four years in New Jersey to 49.2 percent in South Carolina. The national average is 68.3 percent, up 1.0 percent from the past year but lower than the 1990 rate of 72.9 percent.

The largest increases in reported graduation rates since the 2003 Edition occurred in South Dakota (up 5.9 percent) and New York (up 4.3 percent). New York's gain returns it to graduation levels similar to 1998. The largest decreases occurred in Michigan (down 3.2 percent) and in Alaska (down 3.1 percent). Michigan's graduation rates have fluctuated in the last few years - up one year and down the next.

Since the 1990 Edition, New Jersey, California and New Hampshire have increased graduation rates, by 10.1 percent, 1.1 percent and 0.6 percent, respectively. Rhode Island and Utah have the same graduation rate this year as in 1990. Eight states have experienced decreases of more than 10 percent in their graduation rates since the 1990 Edition. These include: Hawaii (down 19.7 percent), South Carolina (down 18.6 percent), Alaska (down 12.9 percent), Alabama (down 12.3 percent), New Mexico (down 11.7 percent), Nevada (down 11.6 percent), Georgia (down 11.4 percent) and Tennessee (down 10.5 percent).

Community Environment

Five measures are used to represent the community environment: the violent crime rate, the percentage of the population who lack health insurance, 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 life 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 number of uninsured population and the socio-economic conditions have a significant relationship to the healthiness of community's residents.

The components 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 five 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.

Violent Crime

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 22 displays the 2004 ranks, based on 2002 data (Crime in the United States: 2002. Washington, D.C., Federal Bureau of Investigation). The rate varies from a low of 78 offenses per 100,000 population in North Dakota, 107 offenses per 100,000 population in Vermont and 108 offenses per 100,000 population in Maine to a high of 770 offenses per 100,000 population in both Maryland and Florida and 822 offenses per 100,000 population in South Carolina. The national average is 495 offenses per 100,000 population, down 10 offenses per 100,000 population from the 2003 Edition and down 114 offenses per 100,000 population from the 1990 Edition.

The largest reported decreases in violent crime in the past year occurred in West Virginia and New Mexico, where offenses decreased by 45 offenses and 41 offenses per 100,000 population, respectively. Twenty-nine other states also experienced decreases. The largest reported increases occurred in South Carolina (from 720 to 822 offenses per 100,000 population) and in Nevada (from 587 to 638 offenses per 100,000 population).

This is the fifth year that the national violent crime rate is lower than the 1990 Edition. However, 21 states have experienced increases, led by Montana, Tennessee, Delaware and South Carolina with increases of 201 offenses, 183 offenses, 167 offenses and 157 offenses per 100,000 population, respectively, since the 1990 Edition. New York and California have reduced violent crime the most since the 1990 Edition, decreasing from 1,007 to 496 offenses per 100,000 population and from 918 to 593 offenses per 100,000 population, respectively.

Lack of Health Insurance

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 and frequently do not participate in preventive care programs.

Table 23 displays the 2004 ranks, based on 2003 data (March 2004 Current Population Survey, Washington, D.C., U.S. Census Bureau). Scores ranged from 8.7 percent in Minnesota to more than 20 percent in Texas, New Mexico, Louisiana and Oklahoma. The national average is 15.6 percent uninsured, up 0.4 percent from the 2003 Edition and up 2.2 percent since 1990.

In the last year, the rate of uninsured population decreased in 11 states including Wyoming (decreased by 1.8 percent), Texas (decreased by 1.2 percent) and Vermont (decreased by 1.2 percent). The rate of uninsured population increased in 38 states, including an increase of 3 or more percent in Montana and Oklahoma.

Infectious Disease

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, the individual state health departments report these diseases, and the level of accuracy may differ from state to state.

Table 24 displays the 2004 ranks, based on 2001 to 2003 data (Mortality and Morbidity Weekly Reports, Centers for Disease Control and Prevention). The rate of infectious disease per 100,000 population varies from a reported low of less than five cases in North Dakota and South Dakota to a reported high of more than 50 cases in New York. The national average is 26.1 cases per 100,000 population, down slightly from 27.0 cases per 100,000 population from the 2003 Edition and down considerably from 40.7 cases per 100,000 population from the 1990 Edition.

Reported infectious disease decreased by 5.0 or more cases per 100,000 population in New Jersey and Mississippi. It increased by 5.3 cases per 100,000 population in Georgia. Since the 1990 Edition, Alaska, Oregon, Washington and Arizona have seen the greatest decreases in reported cases with more than 50 fewer cases per 100,000 population, while only Pennsylvania, Maryland and Georgia have experienced increases in the incidence of infectious disease.

Children in Poverty

Children in Poverty measures the percentage of related persons under age 18 living in a household that is below the poverty threshold. In 2004, the poverty threshold for a household of four people was approximately $18,850 in household income.

Table 25 displays the 2004 ranks, based on 2003 data (March 2004 Current Population Survey, Washington, D.C., U.S. Census Bureau). The percentage of children in poverty ranged from a low of 7.2 percent of persons under age 18 in New Hampshire to a high of more than 26 percent in New Mexico, Arkansas and West Virginia. The national average is 17.6 percent, up 1.3 percent from the 2003 Edition and down 3.0 percent from the 1990 Edition.

In the past year, the percentage of children in poverty increased in 33 states. Children in poverty increased by 5 percent or more in Oregon, Virginia, Washington, Nevada, Iowa, South Dakota, Rhode Island and North Carolina. It decreased by 5 percent or more in South Carolina and North Dakota. Since 1990, children in poverty has increased by 5 percent or more in Rhode Island, Washington and Oregon. It decreased by 10 percent or more in Mississippi, Louisiana, Minnesota and Tennessee.

Occupational Fatalities

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: agricultural, forestry and fishing, construction, manufacturing, transportation and communications, and services.

Table 26 displays the 2004 ranks, based on 2000 to 2002 data (Census of Fatal Occupational Injuries, Bureau of Labor Statistics, Department of Labor, Washington, D.C.). Scores vary from 2.5 deaths per 100,000 workers in Massachusetts to more than 10 deaths per 100,000 workers in Alaska, Wyoming and Montana. The national norm is 4.6 deaths per 100,000 workers, down from 4.7 deaths per 100,000 workers in the 2003 Edition. In Idaho and Montana, the rate of occupational fatalities decreased by 1.0 death or more per 100,000 workers in the past year. Wyoming experienced the greatest increase, from 9.7 to 13.4 deaths per 100,000 workers in the past year.

Health Policies

Three measures are used to represent public health policies and programs: percent of health dollars for public health, per capita public health spending and adequacy of prenatal care. These components are indicative of the availability of resources and the extent of reach of programs.

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.* Individuals can also see the spectrum of options available to states and communities by visiting www.thecommunityguide.org, a website that provides a systemic review of programs and evidence-based recommendations for health and community officials.

Percent of Health Dollars for Public Health

Percent of Health Dollars for Public Health measures the percentage of total health expenditures in a state that are targeted for public or population health programs and initiatives. A high percentage indicates that the state has recognized the cost-effectiveness of public health and is prioritizing its health spending accordingly.

This measure, along with Per Capita Public Health Spending, is new to the 2004 Edition. These two measures replace the earlier measure, Support for Public Health Care. The source data is identical to the previous measure, however the current method more clearly illustrates two critical aspects of public health spending: the priority of the program relative to other programs and total expenditures. The total weight of these two measures has been set at 5.0 percent of the model, identical to the weight of the single measure they replaced. Current public health spending may include considerable amounts of funding designated for homeland security efforts. It is too early to know the effectiveness of these expenditures on the health of the overall population.

Table 27 displays the 2004 ranks, based on 2001 data (National Association of State Budget Officers). It ranges from a high of 34.5 percent of the state health budget spent on public health in Alaska to a low of under 2 percent in Georgia, New Jersey, North Carolina, Connecticut, Idaho and Louisiana.

Per Capita Public Health Spending

Per Capita Public Health Spending measures the dollars per person that are spent on public or population health in a state. This measure is new to the report in this Edition and together with Percent of Health Dollars for Public Health are a replacement for the earlier measure, Support for Public Health Care. High spending on population health programs are indicative of states that are proactively implementing preventive and education programs targeted at improving the health of all populations within a state. Current public health spending may include considerable amounts of funding designated for homeland security efforts. It is too early to know the effectiveness of these expenditures on the health of the overall population.

Table 28 displays the 2004 ranks, based on 2001 data (National Association of State Budget Officers). It ranges from a high of more than $150 spent per person for public health activities in Alaska, Minnesota and Texas to a low of under $15 spent per person in Georgia, New Jersey, North Carolina and Idaho.

Adequacy of Prenatal Care

Adequacy of Prenatal Care is a measure of access to adequate prenatal care based on the Modified Kessner Criteria. The National Center for Health Statistics defines adequate care as having one's first prenatal visit with a health professional within the first trimester of pregnancy and additional visits as per the schedule in Table 11.

Table 29 displays the 2004 ranks, based on 2002 data (National Center for Health Statistics. Adequacy of Care by State, United States, Hyattsville, Md.). Access to adequate prenatal care ranges from 85 percent or more of pregnant women in New Hampshire, Rhode Island, Vermont and Massachusetts to less than 60 percent in New Mexico. The national average is 76.2 percent, almost identical to the 2003 Edition average of 76.0 percent of pregnant women receiving adequate prenatal care. It is an increase of 7.5 percent since the 1990 Edition. The largest increases in access to adequate prenatal care between the 2003 and 2004 Editions occurred in Wyoming (from 70.1 percent to 73.8 percent), Utah (from 58.4 percent to 60.6 percent) and Vermont (from 83.8 percent to 85.8 percent). South Dakota and Georgia reported decreases of 2.6 percent and 2.7 percent, respectively, in the past year.

Since the 1990 Edition, the largest increases in access to adequate prenatal care have occurred in Vermont, Florida, West Virginia and South Carolina (all up 15 percent or more). Utah experienced the largest decrease (from 72.4 percent to 60.6 percent) in access to adequate prenatal care since the 1990 Edition.

The disparities in adequacy of prenatal care within a state are discussed elsewhere in the report.