Measures Selection and Changes

• Represent issues that affect population health.
• Have data available at the state level.
• Use common measurement criteria across the 50 states.
• Are current and updated periodically.
• Are amenable to change.

Annual Report

• Ranking measures (included in overall rank): 49
• Additional measures (not included in overall rank): 38

• Breast Cancer Screening: Percentage of women ages 40-74 who reported receiving a mammogram in the past two years (additional measure).
• Cancer Screenings: Percentage of women ages 40-74 who reported receiving a mammogram in the past two years and percentage of adults ages 45-75 who reported receiving colorectal cancer screening within the recommended time period (additional measure).
• Climate Risks: Percentage of the population living in disadvantaged census tracts (at or above the 90th percentile) based on any of the following risks: agricultural value losses, building value losses, or fatalities and injuries due to 14 types of natural hazards; or projected flood, or wildfire risk (additional measure).
• Homicide: Number of deaths due to injuries inflicted by another person with intent to injure or kill per 100,000 population (ranking measure).
• Housing Cost Burden: Percentage of households with housing costs at more than 30% of household income (additional measure).
• Renewable Energy: Percent of electricity generated from renewable sources (biomass, geothermal, hydroelectric, solar and wind) (additional measure).
• Transportation Health Risks: Percentage of the population living in disadvantaged census tracts (at or above the 90th percentile) based on any of the following risks: diesel particulate matter exposure, transportation barriers, or traffic proximity and volume (additional measure).

• The Behavioral Risk Factor Surveillance System (BRFSS) changed how it categorizes "other race.” Those who selected "other race" in the 2022 survey were imputed into the other race groups. All race/ethnicity data for BRFSS measures in this report were not comparable to prior years.
• Adverse childhood experiences data in this report had repeated data. The National Survey of Children’s Health (NSCH) implemented a new weighting methodology on its 2022 data (i.e., enhanced). The 2022 enhanced data were not comparable to prior years and could not be combined with 2021 data in time for this data update.
• Cancer data in this report were not comparable to prior years. New 2022 BRFSS cancer estimates excluded non-melanoma skin cancer while previous cancer estimates excluded all skin cancers.
• Cannabis data (a subcomponent of the non-medical drug use measure) in this report were not comparable to prior years. The definition for this measure was updated to include THC, CBD and combination products.
• Colorectal cancer screening data in this report were not comparable to prior years. The definition for this measure was updated to reflect updated U.S. Preventive Services Task Force screening recommendations for colorectal cancer screening to start at age 45, rather than age 50.
• Drinking water violations data in this report were not comparable to prior years. The definition for this measure was updated by the source from "severe violations" to "health-based violations".
• Multiple chronic conditions data in this report were not comparable to prior years. The cancer subcomponent of this composite measure had a methodology change making it incomparable to prior years (see Cancer above).
• Premature death racial disparity data in this report had repeated data. The National Center for Health Statistics (NCHS) discontinued production of the bridged race population estimates with July 1, 2020, as the final year of estimates available in the series.
• Rural population data in this report were not comparable to prior years. The source for this data was changed from the U.S. Census Bureau to CDC WONDER, Single-Race Population Estimates to match other population estimates on the America’s Health Rankings platform.

• Ranking measures (included in overall rank): 51
• Non-ranking measures (not included in overall rank): 32
• Subcomponent measures: 3
• Summation measures (category, topics, subtopics and overall): 27

• Firearm deaths​: Deaths due to firearm injury (unintentional, suicide, homicide or undetermined) per 100,000 population.
• High school completion​: Percentage of adults ages 25 and older with at least a high school diploma or equivalent.

• Adverse childhood experiences: Definition was updated to include a new item regarding discrimination based on sexual orientation or gender identity.
• Avoided care due to cost: The 2021 survey question replaced the word ‘cost’ with ‘afford’ to improve the quality of the question as it pertains to affordability rather than avoiding care for other reasons.
• Childhood immunizations: Definition was updated from coverage by age 35 months to age 24 months. This aligns with Healthy People 2030 and allows for more timely data. ​
• Dedicated health care provider: The 2021 survey question was expanded to include groups of doctors in addition to one person who you think of as your personal health care provider to lessen confusion about whether respondents consider professional practices in their response over a single person.
• Economic hardship index: Methodology was updated for the calculation of measure score used in Overall Rank to be consistent with other indexed measures.
• Fourth grade reading proficiency: Measure was promoted from non-ranking to ranking, meaning that it is now included in the calculation of a state’s overall rank.
• Low birthweight disparity: Methodology was updated from a 1-year to a 3-year measure.
• Preventable hospitalizations: Methodology was updated to reflect new Agency for Healthcare Research and Quality inclusion criteria for the indicator PQI 90, dropping dehydration as an ambulatory-care sensitive condition.

• The colorectal cancer screening definition was updated to reflect new recommendations from the U.S. Preventive Services Task Force.
• The race groups for low birthweight and low birthweight racial disparity were updated to reflect single-race categories (replacing the bridged-race categories).
• The residential segregation measure was updated to reflect non-Hispanic white race groups (versus white, including Hispanic) and to reflect household-level (versus population-level) data.
• The data source for risk-screening environmental indicator score revised its data. As a result, 2018 data were updated on the website to reflect this change.
• The data source for transportation energy use changed from the State Transportation Statistics of the U.S. Department of Transportation to the State Energy Data System of the U.S. Energy Information Administration due to a revision by the original data source that also affected the past two years of data. Updated data are available on the website.
• The data source for volunteerism changed from the Corporation for National & Community Service to the Volunteerism and Civic Engagement Supplement of the Current Population Survey.
• The measure 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).

• Fourth grade reading proficiency is the percentage of fourth grade public school students who scored proficient or above on the reading assessment. Source: U.S. Department of Education, National Center for Education Statistics, National Assessment of Educational Progress, 2019.
• Homeownership is the percentage of housing units owned by the occupant. Source: U.S. Census Bureau, American Community Survey, 2019.
• Homeownership racial disparity is the difference in homeownership rate between the non-Hispanic white population and the racial/ethnic population with the lowest rate (varies by state). Source: U.S. Census Bureau, American Community Survey, 2019.

• 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.

• 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.

• 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.

• 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.

• 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.

• 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.

• 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.

• 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.

• 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:

1. 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.
2. 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.
3. 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).

• 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.

Senior Report

• Measures included in a state’s overall rank: 35
• Additional measures (not included in overall rank): 17

• Functional Disability: Percentage of adults age 65 and older who reported having one or more of the following disability types: cognitive, visual, auditory, ambulatory, self-care or independent living difficulties.
• Internet Crime: Number of internet crime victim complaints per 10,000 adults age 60 and older.
• Unpaid Elder Care: Percentage of individuals age 15 and older who reported providing unpaid care or assistance to an adult age 65 or older who needed help because of a condition related to aging.

• The Behavioral Risk Factor Surveillance System (BRFSS) changed how it categorizes "other race.” Those who selected "other race" in the 2022 survey were imputed into the other race groups. All race/ethnicity data for BRFSS measures in this report were not comparable to prior years.
• The Cancer Screenings data in this report were not comparable to prior years. The new 2022 BRFSS cancer estimates excluded non-melanoma skin cancer, while previous estimates excluded all skin cancers.
• The Drinking Water Violations data in this report were not comparable to prior years. The source updated the definition for this measure from "severe violations" to "health-based violations."
• The Low-Care Nursing Home Residents data in this report were not comparable to prior years. The source updated the calculation methodology for this measure, however, the definition remains the same.

• Ranking measures (included in overall rank): 35
• Non-ranking measures (not included in overall rank): 17

• Firearm Deaths – Ages 65+​: Deaths due to firearm injury of any intent (unintentional, suicide, homicide or undetermined) per 100,000 adults ages 65 and older.
• Motor Vehicle Deaths – Ages 65+​: Deaths due to motor vehicle traffic crash on a public roadway per 100,000 adults ages 65 and older.
• Housing Cost Burden – Ages 65+​: Percentage of households with one or more adults ages 65 and older for which housing costs are more than 30% of household income.
• Rural Population – Ages 65+: Percentage of adults ages 65 and older who live in a rural area.

• Avoided Care Due to Cost: The 2021 survey question (was there a time in the past 12 months when you needed to see a doctor but could not because…) replaced the words “of cost”’ with ‘“you could not afford it”’ to improve the quality of the question as it pertains to affordability rather than avoiding care for other reasons. Estimates for this year are not comparable to prior years.
• Dedicated Health Care Provider: The 2021 survey question was expanded to include groups of doctors in addition to one person considered to be a personal health care provider. This change lessened confusion about whether respondents consider professional practices in their response over a single person. Estimates for this year are not comparable to prior years.
• Geriatric Providers: Calculation methods were improved and applied to prior years.​
• Nursing Home Quality: In July 2022, the staffing domain was changed to include new staffing level measures, and the overall rating calculation was changed to reduce the number of stars awarded for the staffing domain. These changes likely caused the universal decrease in the number of four- and five-star nursing homes.​
• Volunteerism: Calculation methods were improved and applied to prior years.

• Ranking measures (included in overall rank): 37
• Additional measures (not included in overall rank): 14
• Subcomponent measures: 11
• Summation measures (category, topics, subtopics and overall): 21

• COVID-19 vaccinations - Ages 65+: Percentage of adults ages 65 and older who were fully vaccinated, defined as having received the second dose in a two-dose COVID-19 vaccine series or one dose of the single-shot J&J/Janssen COVID-19 vaccine.
• COVID-19 vaccinations - booster dose - Ages 65+: Percentage of fully vaccinated people ages 65 and older who later received another dose of any COVID-19 vaccine.

• Cancer screenings: Methodology was updated to reflect new recommendations from the United States Preventive Services Task Force for colorectal cancer screenings.
• Drug deaths: Definition was updated to represent drug deaths among adults ages 65 and older, as opposed to adults ages 65-74.
• Home health care workers: Denominator was previously adults ages 65 and older with a disability. This year, the denominator was updated to represent all adults ages 65 and older.
• Multiple chronic conditions: Source was changed from the Centers for Medicare & Medicaid Services’ Research, Statistics, Data and Systems to its Mapping Medicare Disparities Tool.
• Preventable hospitalizations: Methodology and definition were updated to reflect new Agency for Healthcare Research and Quality inclusion criteria for the indicator PQI 90, dropping dehydration as an ambulatory-care sensitive condition.
• Volunteerism: Source was changed from the Corporation for National & Community Service to the Volunteerism and Civic Life Supplement of the Current Population Survey.
• Voter participation (Average): Measure previously reflected the midterm election. With the release of 2020 presidential data, the measure was updated to represent an average of the past two national elections (midterm and presidential).

• College graduate
• Depression
• Early death racial disparity
• Fruit and vegetable consumption
• High-speed internet
• Poverty racial disparity
• Rural population

• Fruit consumption
• Shingles vaccination
• Vegetable consumption

• 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+.

• 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.

• 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.

• 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.

• 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.

• Community support was renamed community support expenditure.
• Health screenings was renamed cancer screenings.

• Dental visits
• Geriatrician shortfall
• HAI policies
• Prescription drug coverage
• Diabetes management
• Health screenings
• Hospital readmissions
• Preventable hospitalizations
• Falls
• Hip fractures
• Teeth extractions

• 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.

• 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.

• 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
• Volunteerism

• 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.

• 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

• Weighted measures included in a state’s overall rank: 82
• Additional measures not included in overall rank: 41

• Adult Mentor. Percentage of children ages 6-17 who have at least one adult in their school, neighborhood, or community who knows them well and who they can rely on for advice or guidance.
• Congenital Syphilis. Number of new cases per 100,000 live births.
• Mental Health Conditions. Percent of children ages 3-17 told by a health care provider they currently have ADHD, depression, or anxiety problems; or were told by a doctor or educator they have behavior or conduct problems.
• Mental Health Treatment. Percentage of children ages 3-17 with a mental or behavioral condition who receive treatment or counseling.

• Housing Cost Burden - Households With Children. Percentage of households with one or more children younger than 18 years for which housing costs are more than 30% of household income.
• Breastfeeding Initiation. Percentage of infants who were breastfed between birth and discharge from the hospital.

• Severe Housing Problems. This measure was retired and replaced by housing cost burden among households with children.
• Reading, Singing or Storytelling. This measure was moved to an additional measure status and is no longer a weighted measure in the model.

• The Behavioral Risk Factor Surveillance System (BRFSS) changed how it categorizes "other race.” Those who selected "other race" in the 2022 survey were imputed into the other race groups. All race/ethnicity data for BRFSS measures in this report are not comparable to prior years.
• The Cancer Screenings data in this report are not comparable to prior years. The new 2022 BRFSS cancer estimates excluded non-melanoma skin cancer, while previous estimates excluded all skin cancers.
• The Drinking Water Violations data in this report are not comparable to prior years. The source updated the definition for this measure from "severe violations" to "health-based violations."

• Ranking measures (included in overall rank): 83
• Additional measures (not included in overall rank): 39

• High school completion: Percentage of adults ages 25 and older with at least a high school diploma or equivalent.
• Injury deaths - women: Deaths due to injury per 100,000 females ages 20-44.
• Injury deaths - children: Deaths due to injury per 100,000 children ages 1-19.
• Housing cost burden - children: Percentage of households with one or more children younger than 18 years for which housing costs are more than 30% of household income (additional measure).
• Maternity care desert: Percentage of women living in an area identified as a maternity care or low maternity care area (additional measure).

• Florida data were partially available for measures from the Behavioral Risk Factor Surveillance System (BRFSS), as the state was unable to collect data to meet CDC's minimum requirements for inclusion in the 2021 public-use data set. Florida data were missing from the national values for measures using 2021 BRFSS data only. For measures using 2020 BRFSS data only, Florida data were included in the national value. For measures using 2020-2021 BRFSS data, Florida estimates were based on one year of data (2020) and one year is missing (2021). As a result, we encourage readers to use caution when interpreting Florida estimates in this report.
• The National Survey on Drug Use and Health (NSDUH) retracted its 2020 data due to methodological concerns identified after release. No new 2020-2021 NSDUH data were available this year due to this, as well as a methodology change in the 2021 survey preventing comparison to prior years. All NSDUH measures in this report had repeated data from 2018-2019 data years, which were used to calculate the state rankings.
• The National Survey of Children’s Health (NSCH) implemented a new weighting methodology on its 2022 data (i.e., enhanced). The 2022 enhanced data were not comparable to prior years and cannot be combined with 2021 data in time for this data update. All NSCH measures in this report had repeated data.
• Some 2021 BRFSS survey questions were modified to improve the quality of questions. Estimates for the measures avoided care due to cost and dedicated health care provider in this report were not comparable to prior years.
• The U.S. Department of Agriculture (USDA) re-estimated its 2016-2019 WIC Eligibility and Coverage data while producing 2020 estimates. WIC coverage data in this report were not comparable to prior years.

• Ranking measures (included in overall rank): 84
• Non-ranking measures (not included in overall rank): 37
• Subcomponent measures: 24
• Summation measures (category, topics, subtopics and overall): 48

• Firearm deaths - Ages 1-19​: Deaths due to firearm injury per 100,000 children ages 1-19.
• Firearm deaths - Women - Ages 20-44​: Deaths due to firearm injury of any intent (unintentional, suicide, homicide or undetermined) per 100,000 females ages 20-44.
• Neonatal abstinence syndrome: Number of birth hospitalizations with a diagnosis code of neonatal abstinence syndrome (withdrawal symptoms due to prenatal exposure to illicit drugs) per 1,000 birth hospitalizations.

• Adverse childhood experiences: Definition was updated from eight items to nine items. The new item is 'being treated or judged unfairly due to their sexual orientation or gender identity.'
• Childhood immunizations: Definition was updated from coverage by age 35 months to age 24 months. This aligns with Healthy People 2030 and allows for more timely data. ​
• Low birthweight disparity. Methodology was updated from a 1-year to a 3-year measure.
• Maternal mortality: Source was changed from CDC WONDER single-year estimates to FAD 5-year estimates. This maintains a consistent definition (which also matches the World Health Organization’s definition), uses new National Vital Statistics System methodology and provides more state and subpopulation data. ​This is a non-ranking measure.
• Severe maternal morbidity: Custom maternal morbidity measure (CDC WONDER 3-year estimate) was replaced with severe maternal morbidity measure (FAD single-year estimate), resulting in source, definition, methodology and measure name changes. This aligns with the CDC’s definition of severe maternal morbidity, captures more instances of maternal morbidity, aligns with the Title V National Outcomes Measures from the Maternal and Child Health Bureau and provides additional subpopulation data.​ This is a non-ranking measure.

• 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 race groups for low birthweight, low birthweight racial disparity, mortality —women and infant mortality were updated to reflect the single-race categories (as opposed to bridged-race categories.
• 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).

• 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.

• Excessive drinking
• Obesity
• Overweight or obesity

• High school graduation

• Adverse childhood experiences
• Neighborhood amenities
• Concentrated disadvantage
• Food insecurity - household

• Household Smoke

• Childhood immunizations
• mPINC
• Postpartum visit
• Publicly-funded women’s health services
• Uninsured women
• Policy to Physical Environment
• Water fluoridation

• Teen births
• Unintended pregnancy
• Diabetes-women (subpopulation of Multiple chronic conditions)
• Drug deaths-women
• Maternal mortality
• Neonatal mortality
• Teen suicide

• Low-risk cesarean delivery
• mPINC
• Smoking during pregnancy

• Breastfed
• Infant mortality
• Low birthweight
• Sleep position

• Cervical cancer screening
• Dental visit
• Intimate partner violence - Lifetime
• mPINC
• Publicly-funded women’s health services
• Protective family routines and habits (Ages 0-17)
• Water fluoridation

• 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

• 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

Health of Those Who Have Served Report

Health of Women Who Have Served Report