Appendix Methodology | 2023 Annual Report

Executive Brief Introduction National HighlightsFindingsHealth Outcomes Social and Economic Factors Physical Environment Clinical Care State Rankings International ComparisonAppendixMeasures Table Data Source Descriptions MethodologyState Summaries
US Summary
2023 Annual Report – Executive Brief 2023 Annual Report 2023 Annual Report – State Summaries 2023 Annual Report – Economic Hardship Index County-Level Maps 2023 Annual Report – Measures Table 2023 Annual Report – Infographics 2023 Annual Report – Report Data (All States)
Individual Measures
This year, 87 measures (including 49 ranking and 38 additional measures) were analyzed for the America’s Health Rankings 2023 Annual Report, using the most recent data available as of October 30, 2023. Data years varied by measure because of the variety of data sources. For some measures, multiple data years were combined to ensure reliable state-level estimates. Measure definitions, sources and data years are available in the Appendix: Measures Table. Measure changes were based on input from the Advisory Committee.
Each state was ranked according to its value for each measure, with a rank of 1 assigned to the state with the healthiest value. Ties in value were assigned equal ranks. If a state value was not available for a measure in this edition, the state value was noted as unavailable or suppressed. It is important to note that rankings are a relative measure of health. Not all changes in rank translate into actual declines or improvements in health. For additional methodology information, submit an inquiry at Americashealthrankings.org/about/page/submit-an-inquiry.
How State Rankings Were Generated
Summations were generated overall and by model category and health topic. They show how a state compared with other states overall or for a model category, such as social and economic factors. 
Overall state rankings were based on 49 weighted measures that met the following criteria:
Represented issues that affect population health. 
Had data available at the state level. 
Used common measurement criteria across the 50 states.
Were current and updated periodically.
Were amenable to change. 
The state value for each measure was normalized into a z-score, referred to as “score”, using the following formula: 
The score indicates the number of standard deviations a state value was above or below the U.S. value. Scores were capped at +/- 2.00 to prevent an extreme score from excessively influencing the state’s overall score. If a U.S. value was not available from the original data source for a measure, the mean of all states and the District of Columbia was used. If a value was not available for a state, its value from the most recent available data year was used to generate a score. 
Summation scores were calculated by adding the products of the score for each measure multiplied by that measure’s assigned model weight and association with health. Measures positively associated with population health, such as volunteerism and flu vaccination, were multiplied by 1, while measures with a negative association, such as smoking and premature death, were multiplied by -1. A state that ranked No. 1 had a higher summation score (e.g., 2.00), reflecting better health than a state that ranked No. 50 with a lower summation score (e.g., -2.00). Overall state rank was calculated by ranking the overall summation score, which included all 49 measures with weights in the model (see Measures, Weights and Direction for model and measure weights).
Scores and ranks were not calculated for the District of Columbia because of its unique status as an entirely urban population with different governing and funding mechanisms than states. While the District of Columbia was not included in the rankings, data for the District of Columbia are available in this report and on the America’s Health Rankings website.
Data Notes
Data presented in this report were aggregated at the state level and cannot be used to make inferences at the individual level. Additionally, estimates cannot be extrapolated beyond the population upon which they were created. Values and ranks from prior years were updated on the America’s Health Rankings website to reflect known errors or updates from the reporting source.
Caution is suggested when interpreting data on certain health and behavioral measures. Many were self-reported and relied on an individual’s perception of health and behaviors. Additionally, some health outcome measures were based on respondents being told by a health care professional that they had a disease and may have excluded those who have not received a diagnosis or sought or obtained treatment.
Significance is based on non-overlapping 95% confidence intervals when comparing data over time or across demographic subpopulations.
 Subpopulation Group Definitions
Subpopulation analyses were performed to illuminate disparities by age, disability status, education, gender and sexual orientation, income, metropolitan status, race/ethnicity and veteran status. Not all subpopulations were available for all data sources and measures. Individual estimates were suppressed if they did not meet the reliability criteria laid out by the data source or by internally established criteria. Some values had wide confidence intervals, meaning the true value may be far from the estimate listed.
Age
Age data in this report were available for measures from the Centers for Disease Control and Prevention’s (CDC's) Behavioral Risk Factor Surveillance System (BRFSS) and CDC WONDER. BRFSS groupings included the following age ranges: 18-44, 45-64 and 65+. CDC WONDER groupings included the following age ranges: 15-24, 25-34, 35-44, 45-54, 55-64, 65-74, 75-84 and 85+. 
Disability Status
Disability status data in this report were available for measures from BRFSS. Groupings were based on responses to the questions in the core Disability section. Responses of yes to the question, “Are you deaf or do you have serious difficulty hearing?” were coded as difficulty hearing. Responses of yes to the question, “Are you blind or do you have serious difficulty seeing, even when wearing glasses?” were coded as difficulty seeing. Responses of yes to the question, “Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?” were coded as difficulty with cognition. Responses of yes to the question, “Do you have serious difficulty walking or climbing stairs?” were coded as difficulty with mobility. Responses of yes to the question, “Do you have difficulty dressing or bathing?” were coded as difficulty with self-care. Responses of yes to the question, “Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping?” were coded as independent living difficulty. Responses of no or missing to all questions, with at least one response being no, were coded as without disability.
Education
Education data in this report were available for measures from BRFSS and the Researched Abuse, Diversion and Addiction-Related Surveillance (RADARSⓇ) System. BRFSS groupings were limited to ages 25 and older and were based on responses to the question, “What is the highest grade or year of school you completed?” A response of grades 9 through 11 was classified as less than high school. A response of grade 12 or GED was classified as high school or GED. A response of college or technical school 1 year to 3 years was classified as some post-high school. A response of college 4 years or more was classified as college graduate. RADARS groupings were limited to ages 18 and older and were based on responses to the question, “What is the highest degree or level of school you have completed? Select one.” A response of less than a high school diploma was classified as less than high school. A response of regular high school diploma, GED, or alternative credential was classified as high school graduate or GED. Responses of some college credit, but no degree, trade school and associate’s degree (for example, AA, AS) were classified as some college or trade school. Responses of Master’s degree (for example, MA, MS, MEng, Med, MSW, MBA), or doctorate or Professional degree (for example, PhD, EdD, JD, MD) were classified as college graduate.  
Gender
This report stratified gender as men and women for adults and female and male for data including children as available through public data sources — even though not all people identified as belonging to one of these two categories. Data did not differentiate between assigned sex at birth and current gender identity. While sex and gender influence health, the current data collection practices of many national surveys limited the ability to describe the health of transgender or gender nonbinary individuals, especially at the state level. 
Income
Income data in this report were available for measures from BRFSS and RADARS. BRFSS groupings were limited to ages 25 and older and were based on responses to the question, “[What] is your annual household income from all sources?” Responses of less than $10,000, $10,000 to less than $15,000, $15,000 to less than $20,000 and $20,000 to less than $25,000 were summed and classified as less than $25,000. Responses of $25,000 to less than $35,000 and $35,000 to less than $50,000 were summed and classified as $25,000-$49,999. Responses of $50,000 to less than $75,000 were classified as $50,000-$74,999. Responses of $75,000 or more were classified as $75,000 or more. RADARS groupings were limited to ages 18 and older and were based on responses to the question, “What was your combined household income during the last 12 months? Select one.” A response of less than $25,000 was classified as less than $25,000. Responses of between $25,000 and $49,999 and between $50,000 and $74,999 were classified as $25,000 to $74,999. Responses of between $75,000 and $99,999 and $100,000 or more were classified as $75,000 or more.
Metropolitan Status
Metropolitan status data in this report were available for measures from BRFSS. Groupings were coded based on residence geography. Identification as large central metro, large fringe metro, medium metro and small metro were classified as metro, and identification as micropolitan and noncore were classified as non-metro. 
Race and Ethnicity
Data were provided where available for the following racial and ethnic groups: American Indian/Alaska Native, Asian, Black or African American (classified in this report as Black), Hispanic or Latino (classified as Hispanic), Native Hawaiian or Other Pacific Islander (classified as Hawaiian/Pacific Islander), white, multiracial and those who identify as other race. Hispanic ethnicity includes members of all racial groups. Racial/ethnic groups were defined differently across data sources (details below). In summary, while American Community Survey data were presented as Hispanic-inclusive (except for white, which is non-Hispanic), all other sources presented race data as non-Hispanic. Those include BRFSS; CDC National Center for HIV, Viral Hepatitis, STD and TB Prevention (NCHHSTP); CDC WONDER; the U.S. Department of Housing and Urban Development (HUD); and RADARS.
Race and ethnicity categories by source:
American Community Survey: American Indian and Alaska Native; Asian; Black or African American; Hispanic or Latino Origin (any race); Native Hawaiian or Other Pacific Islander; white (non-Hispanic); two or more races; and some other race.
BRFSS: American Indian/Alaskan Native (non-Hispanic); Asian (non-Hispanic); Black or African American (non-Hispanic); Hispanic, Latino/a or Spanish origin (any race); Native Hawaiian or Other Pacific Islander (non-Hispanic); white (non-Hispanic); multiracial (non-Hispanic); and other race (non-Hispanic).
CDC NCHHSTP: American Indian or Alaska Native (non-Hispanic); Asian (non-Hispanic); Black or African American (non-Hispanic); Hispanic or Latino/a (any race); Native Hawaiian or Other Pacific Islander (non-Hispanic); white (non-Hispanic); and more than one race (non-Hispanic).
CDC WONDER: American Indian or Alaska Native (non-Hispanic); Asian (non-Hispanic); Black or African American (non-Hispanic); Hispanic (any race); Native Hawaiian or Other Pacific Islander (non-Hispanic); white (non-Hispanic); and more than one race (non-Hispanic).
HUD: American Indian or Alaska Native (non-Hispanic); Asian (non-Hispanic); Black or African American (non-Hispanic); Hispanic (any race); Pacific Islander (non-Hispanic); white (non-Hispanic); and other race, including multiple races (non-Hispanic).
RADARS: American Indian/Alaska Native (non-Hispanic); Asian (non-Hispanic); Black (non-Hispanic); Hispanic (any race); Hawaiian/ Pacific Islander (non-Hispanic); white (non-Hispanic); and other race (non-Hispanic).
Sexual Orientation
Sexual orientation data in this report were available for measures from BRFSS. Groupings were based on responses to the question, “Which of the following best represents how you think of yourself?” Responses of lesbian or gay, gay, bisexual or something else were summed and classified as LGBQ+. Responses of straight were summed and classified as straight (heterosexual or not gay). 
Veteran Status
Veteran status data in this report were available for measures from BRFSS. Groupings were based on responses to the question, “Have you ever served on active duty in the United States Armed Forces, either in the regular military or in a National Guard or military reserve unit?” Responses of yes were summed and classified as served. Responses of no were summed and classified as not served.
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