How hazardous is your state to your health?
Abstract: Rankings in our society are ubiquitous. States are often ranked on indicators such as education, income, taxes, health status, eco-friendliness, and pollution. This study ranks states on how hazardous they are to the health of the citizenry in terms of their policies, expenditures, and regulations. States were ranked (1 for best and 50 for worst) for each variable within each of four categories (health promotion, health protection, the environment, and economic well-being) as well as an overall ranking. Policy makers, state legislators and civic and professional organizations, as well as concerned individuals, may use these rankings to initiate or enhance policies and regulations. Health administrators, public health and health care professionals may use these rankings to determine methods for improving and enhancing the health services, programs, and behaviors in their communities. Overall the state rankings were varied. In general, states that ranked high in the overall category scored relatively high in all categories. However, exceptions were noted. An association was found between how states voted in the 2008 Presidential Election and how they ranked in terms of being hazardous to population health.
Subject: Physical fitness
Health care reform
Income tax
Public health
Tax law
Authors: Hemphill, Julia
O'Rourke, Thomas
Zachary, Blake
Pub Date: 01/01/2010
Publication: Name: American Journal of Health Studies Publisher: American Journal of Health Studies Audience: Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 American Journal of Health Studies ISSN: 1090-0500
Issue: Date: Wntr, 2010 Source Volume: 25 Source Issue: 1
Topic: Event Code: 920 Taxes Computer Subject: Tax law
Product: Product Code: 8000120 Public Health Care; 9005200 Health Programs-Total Govt; 9105200 Health Programs; 9101100 Tax Law NAICS Code: 62 Health Care and Social Assistance; 923 Administration of Human Resource Programs; 92312 Administration of Public Health Programs; 92113 Public Finance Activities
Organization: Government Agency: United States. Centers for Disease Control and Prevention
Accession Number: 308741527
Full Text: INTRODUCTION

Rankings in our society are ubiquitous. These include rankings of companies, cities, universities, and vacation resorts. States are often ranked on indicators such as education, income, taxes, health status, eco-friendliness and pollution. Rankings can be used for many purposes. They may be used by politicians, policy makers, bureaucrats, businesses, and interest groups, as well as individuals, to advocate for change or maintenance of the status quo. Individuals may find rankings useful for seeking employment, business opportunities, or a wide range of quality of life issues such as where to live and work.

On March 23, 2009, USA Today published an article ("Study measures states by personal, economic freedoms", page 4) by Julie Carr Smyth of the Associated Press that summarized a study conducted by William Ruger and Jason Soren for the Mercatus Center at George Mason University (2009). It received media attention for their ranking of states based on an index of "personal and economic freedom." The study examined state and local interventions across a variety of public policies, such as seat belt laws, tobacco taxes, drug policies, minimum wage, and home school laws. These variables were then ranked by each state according to how much "individual freedom" they allowed. For example, stringent seat belt or motorcycle helmet laws were considered infringing on personal freedoms, so states with the most stringent laws were ranked low on the "freedom" scale.

On the opposite end of the spectrum, state policies and regulations can promote the well-being and safety of individuals. The absence of these regulations can be viewed as hazardous to your health. As Ruger and Soren classified laws such as seat belt laws as infringing upon personal freedoms, we view these laws as protecting the safety and health of individuals (Ruger & Soren, 2009). State laws such as speed limits ensure the safety of drivers by providing safe guideline for speeds and without speed limits, roads and highways would become extremely dangerous for individuals. Other laws such as smoking bans help protect individuals' health and ensure them a safe, clean environment in certain public places, free of harmful tobacco smoke. As state laws and policies play such a vital role in the health and safety of individuals, states lacking these policies can be considered hazardous to your health.

PURPOSE OF THIS STUDY

According to the World Health Organization, health is a result of genetic predisposition, environment and the community in which we live, public and health policies and practices of our government, and medical care (Evidence Base of Health Determinants, 2009). In contrast to the Ruger and Jason Soren study, this study ranks states on how hazardous they are to the health of the citizenry in terms of their policies, expenditures and regulations. In order for greater specificity, we will not only provide an overall ranking, but rankings for various categories. These categories are comprised of health promotion, health protection, the environment, and economic well-being.

SIGNIFICANCE OF THE STUDY

In our view, policies and regulations, which encourage and maintain the health of residents are important. The lack of such policies and regulations can be hazardous to one's health. This study may provide useful information to a variety of stakeholders. Policy makers and state legislators may use these rankings to develop and improve policies and regulations. Similarly, health administrators, public health professionals, and health care employees may use these rankings to determine methods to improve and enhance the health services, practices and health status in their communities. The media may use these data to enhance the public's awareness of the policies, programs, and regulations within their states that promote safety and well-being as well as how well their state ranks in promoting these aspects compared to other states. Individual citizens and organizations may use the rankings to decide which state best fits the health and safety needs for themselves and their family, and become involved in health policies and regulations in their states and communities.

METHODS AND DATA COLLECTION PROCEDURES

For the purposes of this study we utilized a multistage process. To begin, after explaining the purpose of our study, we asked experts in the field of public health to suggest variables to use in the study. We reviewed statistical information on different state rankings from "Freedoms in the 50 States" (Ruger & Soren, 2009), America's State Rankings (The United Health Foundation, 2008), and Kaiser's Family State Health Facts (2008). After reviewing these sources we returned to our group of experts to refine and categorize our variables. We selected 25 variables in four categories. They include:

* Health Promotion: Any activity that promotes or supports the initiation or maintenance of a behavior conducive to health.

* Health Protection: Any activity undertaken by a third party, such as governmental institution or business, to enhance or maintain the health of citizens.

* The Environment: Planned and structured interventions to the physical or social environment to enhance or maintain the health of citizens or to support change or maintenance of a behavior conducive to health.

* Economic Well-being: Any activity or funding that promotes or supports the economic wellbeing of citizens.

After identifying the 25 variables, we placed them into one of the four categories and entered the data for analysis using SPSS Version 17. The 25 variables and ranking systems include:

HEALTH PROMOTION (7 VARIABLES)

Tobacco Prevention--Tobacco has been associated with an increased risk of throat cancer, heart attack, raised blood pressure, lung cancer, respiratory disease, and other diseases. State spending on tobacco prevention helps promote awareness of the effects of smoking. The American Lung Association, in State of Tobacco Control 2008, provided grades of A, B, C, D, or F to all states based on how much they spent on tobacco prevention and control (2008). The grades were based on how states established tobacco programs based on the Centers for Disease Control and Prevention's (CDC) five components critical to a tobacco control program. These components include state and community interventions, health communication interventions, cessation intervention, surveillance and evaluation, and administration and management. The scores were also based on the CDC's recommendation of overall level of funding for each state's tobacco control program (2008). We converted their grades to numeric scores where A = 1, B = 2, etc. States that had been given the same grade were considered tied. Tied states were all given a mean ranking. For example, if 5 states were rated 1 (A), all were given a ranking of 3 on the scale of 1 to 50.

Beer Tax--Alcohol consumption increases the risk for cardiovascular disease, stroke, depression, and other diseases. States with higher beer taxes provide a negative incentive for residents to buy beer. Using data from the Tax Foundation, we ranked the states from 1 to 50 based on beer taxes per gallon, where the state with the highest beer tax was ranked 1 and the state with the lowest beer tax 50 (State Sales, Gasoline, Cigarette, and Alcohol Tax Rates by State, 2009).

Immunization Coverage--Immunizations are important for preventing the development and spread of disease. In their 2008 report, America's Health Rankings, the United Health Foundation ranked states by their immunization coverage of children ages 19 to 35 months. The immunizations included in the study are the suggested early childhood vaccinations including DTP, Poliovirus, MCV, HiB, and HepB. Early childhood immunization is a safe and cost-effective method for controlling diseases in a population (America's Health Rankings 2008: Immunization Coverage, 2008). The state with the highest percentage of immunization coverage of children ages 19 to 35 months received the highest score of 1.

Sexually Transmitted Disease (STD) Prevention Spending Per Capita--Sexually transmitted diseases are an increasing problem in the U.S. Through education and prevention programs, citizens can learn how to prevent and protect themselves from STDs. Based on the Kaiser Foundation's State Health Facts, we ranked states on how much they spent on STD prevention (The Kaiser Foundation, 2007). We first took the amount spent in each state in 2007 according to Kaiser and then divided this number by the population in 2007 to obtain the amount spent per capita. We then ranked each state based on how much they spent on STD prevention per capita, where 1 was the highest amount per capita.

Required Physical Education--Obesity is linked with diseases such as cardiovascular disease and diabetes. Lack of adequate exercise is major risk factor for obesity. Physical education in schools is an effective way to prevent childhood obesity and promote physical activity among youth. Based on information provided by the National Conference of State Legislatures, we rated states 1 to 6 based on their required amount of physical education (Physical Education and Physical Activity for Children, 2005). The highest score of 1 was given to states requiring physical education K-12 with duration or frequency standards. A score of 2 was given to states requiring physical education K-12 with no duration or frequency standards. A score of 3 was given to states requiring elementary and/or middle school physical education with duration standards and some high school physical education requirements. A score of 4 was given to states that had physical education required in varying grade levels and no high school physical education requirements. A score of 5 was given to states that required only some high school physical education to graduate. The lowest score of 6 was given to states that required no physical education at the state level.

Cigarette Tax--Cigarettes are associated with an increased risk of diseases such as throat cancer, lung cancer, and respiratory disease. Cigarette taxes add a negative incentive to smokers as well as those considering smoking. Based on data provided by the Tax Foundation, we ranked states on their cigarette tax per pack (State Sales, Gasoline, Cigarette, and Alcohol Tax Rates by State, 2009). The higher the state taxes on cigarettes, the higher the ranking the state received.

Child Care Regulation--Child care regulations insure the safety and quality of care for children attending child care facilities. In the National Association for Child Care Resources and Referral Agencies report, We Can Do Better: NACCRRA's Ranking of State Child Care Stands and Oversight, each state was scored out of 100 based on regulations in child care facilities. Some of the regulations include: staff to children ratios, background check requirements, health and safety requirements, and education qualifications and annual training requirements for teachers (2007). We used these scores to rank states from 1 to 50; the state with the highest score from NACCRRA received a score of 1.

HEALTH PROTECTION (8 VARIABLES)

Driver Safety--State driving laws are important for protecting the safety of individuals on the roads. In the report, How State Laws Measure Up, states were graded based on state laws promoting driver safety. The states were ranked in six different categories including DUI/DWI, young drivers licensing, safety belt use, child restraint use, motorcycle helmet use, and red light cameras (Insurance Institute for Highway Safety, 2009). Each state received a score of good, fair, marginal, or poor for each of the six categories. After converting the scores to a numeric scale of 1 to 4, we combined the scores from all six categories and developed an average score for each state. Finally, we ranked states 1-50 based on these averages.

Gun Control--Gun control laws are important for preventing individuals from unsafe gun practices and promoting the importance of gun safety. In 2008, the Brady Campaign, a national organization dedicated to prevent gun violence, created a state scorecard ranking of 1 to 50 based on state gun laws (Brady Campaign State Scorecard Rankings). The Scorecard is based on 100 points across five major categories of laws: curbing firearm trafficking, strengthening Brady background checks, child safety, banning military-style assault weapons, and making it harder to carry guns in public places. The state with the highest score received the rank of 1.

Emergency Preparedness--In emergency situations it is important for a state to have a plan to distribute resources and protect citizens. In 2009, the Trust for America's Health created a report scoring each state from 1 to 10 based on their total emergency preparedness, including plans for distributing emergency vaccine and medical supplies, and other plans needed for a public health or bioterrorism emergency (Total Emergency Preparedness State Score). We then ranked each state 1 to 50 based on their scores.

Rural Speed Limits--Speed limits are necessary to ensure drivers are maintaining safe driving practices. Using information provided by Insurance Institute for Highway Safety, we ranked states by their maximum rural speed limits (Maximum Posted Speed Limit, 2009). States with lower speed limits received higher rankings than those that had higher speed limits.

Urban Speed Limits--Similarly to rural speed limits, we ranked maximum urban speed limits based on information provided by the Insurance Institute for Highway Safety (Maximum Posted Speed Limit, 2009). States with lower speed limits received higher rankings than those that had higher speed limits.

Fluoridation--Fluoridation of water helps prevent dental decay and promote dental health. The National Institute of Dental and Craniofacial Research ranked each state 1 to 50 based on the community water fluoridation status of each state (Community Water Fluoridation Status by State, 2009). States with the highest percentages of the population receiving fluoridated water received the highest rankings.

Public Health Funding--Public health funding enables states to develop programs and provide resources to promote the health of the public. The United Health Foundation, in their report America's Health Rankings 2008, developed state rankings measured by dollars per person spent on public or population health received from the Centers for Disease Control and Prevention (CDC), the Health Resources Services Administration and the state (2008). States that spent more on public health received higher rankings.

Mental Health Care Funding--Mental health care spending provides resources for individuals with mental health needs. Based on information provided in the Mental Health America's report, Ranking America's Mental Health: An Analysis of Depression Across the States, we ranked states 1 to 50 based on their per capita spending on state mental health in 2007 (Mark, Shern, Bagalman, & Cao).

ENVIRONMENT (5 VARIABLES)

Parks and Recreation Funding--Parks and other recreational resources can impact physical and mental health. Based on information provided by the U.S. Census Bureau in 2000, states were ranked by their expenditure per capita on parks and recreation (State and Local Government Finances and Employment). Using the total money spent by each state, we divided this number by the population in 2000 to find the per capita spending. The more a state spent on parks and recreation, the higher their rank.

Bike Friendliness--States that promote a safe environment for bicycles provide more opportunities to be physically active. The League of American Bicyclists ranked states 1 to 50 based on six key areas to develop an overall score of bike friendlessness. The six areas were legislation, policies and programs, infrastructure, education and encouragement, evaluation and planning, and enforcement (2009 State Rankings, 2009).

State Environmental Output--Environmental hazards can negatively affect the health of individuals. In the study State Environmental Outputs, states were ranked based on their environmental outputs. These outputs were based on air, water, lakes, ozone, and river factors in relation to state policies (List & McHone, 2000).

Environmental Protection Programs--Protecting the environment can help prevent environmental hazards. Based on data provided by the Environmental Council of the States, we ranked the states on their environmental spending (State Environmental Budgets and Budget Plans, FY 20052008, 2008). Using the amount of funding spent on environmental programs in 2006, we divided this amount by the population of each state in 2006 to obtain the per capita spending. We then ranked the states 1 to 50 based on their per capita spending.

Highway Spending--In order to protect the safety of individuals on the road, highways must be maintained. Based on information provided by the U.S. Census Bureau in 2000, we obtained the amount of highway spending in each state (State and Local Government Finances and Employment). We then took this amount and divided it by the state's 2000 population to develop a per capita spending on highways. Each state was ranked 1 to 50 based on their per capita spending on highway spending.

ECONOMIC WELL-BEING (5 VARIABLES)

Education Spending--Education is associated with better economic and health outcomes. In order to rank states based on their education spending, the elementary and secondary educational spending in 2007, provided by Kaiser State Health Facts, was divided by the 2007 state population to obtain a per capita spending on education (Distribution of State General Fund Expenditures (in millions), SFY2007). Each state was than ranked 1 to 50 based on their per capita spending on elementary and secondary education.

Special Education--Special education is important to provide resources to advance the well-beings of individuals with special needs. Based on data provided by the U.S. Census in 2000, state spending on special education was obtained (State and Local Government Finances and Employment). The total amount spent in each state was divided by the 2000 state population to find the per capita spending on special education. States were then ranked 1 to 50.

Public Assistance--Public assistance helps provide resources to individuals in need. Based on information provided by the Kaiser Foundation, the public assistance spending in 2007 was divided by the 2007 state population to obtain each state's per capita spending on public assistance (Distribution of State General Fund Expenditures (in millions), SFY2007).

Minimum Wage--Many people live on minimum wage pay. High minimum wages provide individuals with higher income to promote their overall well-being. Based on data provided by the U.S. Department of Labor, states were ranked 1 to 50 based on their minimum wage in 2009 (Wage and Hour Division).

Sales Tax--Sales tax is a regressive tax, as it places a burden on lower income individuals who have to pay a larger percentage of their income. Based on data provided by the Tax Foundation, states were ranked based on the amount of their sales tax (State Sales, Gasoline, Cigarette, and Alcohol Tax Rates by State, 2009). States that had a lower sales tax ranked better than states that had a high sales tax.

LIMITATIONS OF THE STUDY

The rankings in this study are based on 25 variables. Clearly there are many others that could have been included. To address this concern we selected variables identified by a pool of public health and health education experts both in academe and in practice. Nor do we imply that our list is a definitive ranking. Use of other variables would likely result in somewhat different findings. However, correlation coefficients among most variables indicate a positive correlation that would probably occur with other similar variables. Ranking in this study should be considered flexible in that they are subject to change on an ongoing basis. For example, most states have increased tobacco taxes and smoke free laws significantly over the past few years. Further changes are likely to be enacted.

In addition, the data for all variables are not from the same year due to data availability. However, data used to rank each individual variable are from the same year and all variables are from data within a relatively narrow time frame in an attempt to minimize significant variations over time.

This study was limited to state policies and expenditures. A state that received a low rank does not necessarily translate into poor population health. Many towns and municipalities address some of the variables found in this study. Unfortunately, the extent of their efforts is unknown. However, our study does inform how states address population health on a state level.

DATA ANAYLSIS

Prior to ranking we present the findings of the 25 variables in the four categories in terms of the mean, median, and highest and lowest ranking states.

Ranking by Category--States were ranked (1 for best and 50 for worst) for each variable within each of the four categories. Rankings for variables within each category were then averaged for each state. Average scores were then ranked from 1 to 50 for each of the four categories.

Overall Ranking--An overall ranking of states was calculated by averaging the ranks for all 25 variables and then ranking the average score for each state.

To assess associations between categories and overall ranking we ran correlations using SPSS Version 17.

Finally, to augment tabular data we utilized ArcView, a Geographic Information System (GIS) software product. Using ArcView, we created layered maps which provided a pictorial and spatial presentation of the ranking for each category and overall ranking.

RESULTS AND DISCUSSION

Results of the 25 variables in the four categories in terms of the mean, median, best (lowest number) and worst (highest number) are presented in Table

1.

HEALTH PROMOTION

Tobacco Prevention and Control--Tobacco prevention programs can decrease the incidence of smoking particularly in youth through education. Furthermore, they can provide support programs for current smokers and increase the awareness of the negative consequences of smoking. We converted their grades to numeric scores where A = 1, B = 2, etc. obtained from The American Lung Association's report, State of Tobacco Control 2008. The finding that only two states, Alaska and Delaware received the highest score of 5 while 41 states received the lowest ranking was discouraging. While it appears that some have improved their score over the past several years, it is clear that there is significant room for improvement.

Beer Tax per Gallon--Taxes on beer showed a wide variation with Wyoming the lowest at $0.02 cents per gallon and Arkansas significantly higher at $1.07. The median tax was $0.19 and the mean tax higher at $0.28 due to several states with much higher taxes. Only a quarter of the states have more than a $0.33 tax. Given the wide variation it would seem that states with low taxes might consider increasing this tax.

Immunization Coverage--Rankings of immunization coverage were based on America's Health Rankings, of the United Health Foundation (America's Health Rankings 2008: Immunization Coverage, 2008). In their 2008 report, immunization ranged from more than 90% in New Hampshire and Maryland to less than 70% in Nevada, with 32 of the states having 80% or less immunization coverage. While none of the states fall under 66% of immunization coverage, many states are failing to cover 20% of their populations, which could affect the control of diseases within the states.

Sexually Transmitted Disease (STD) Prevention Spending Per Capita--As with most variables a wide range was reported in STD prevention spending per capita with Maryland ranking first and Virginia last. Spending was also normally distributed as evidenced by similarity of mean spending of $0.39 and median spending of $0.37. With the rising rates of STDs in the youth of the U.S., states should consider better funded prevention of these diseases.

Required Physical Education--Based on information provided by the National Conference of State Legislatures, we ranked states 1 to 6 based on their required education as previously described. Overall, states scored in the middle with a score of 3; that is, requiring elementary and/or middle school physical education with duration standards and some high school physical education requirements. Only two states (Illinois and New York) received the highest ranking while Colorado and South Dakota received the lowest ranking, requiring no physical education requirement at the state level. Room for significant improvement appears to exist.

Cigarette Tax Per Pack--The association between better smoking and lung cancer has been well publicized for many years, yet people continue to smoke. One way to get people from participating in this unhealthy behavior is to add a negative incentive such as cigarette tax. The price elasticity of cigarettes has been well established, with higher costs associated with reduced consumption. The state with the highest cigarette tax of $3.46 was Rhode Island. On the other end, South Carolina had the lowest cigarette tax of $0.07. From these two states it is apparent there is a wide range of cigarette taxes. Most states had a cigarette tax of less than $2.00, with only 10% of the states having a cigarette tax higher than this amount. With cigarettes taxes so critical to the incidence and prevalence of smokers, some states may want to reconsider their low cigarette tax. The trend toward higher taxation by many states is encouraging.

Child Care Regulation--For child care regulations, the average mean score for the states was 55, which is almost half of the maximum score. In fact, 90 percent of the states scored a 72 or below. Rhode Island received the highest score of 85 while Idaho received the lowest score of 13. Based on the relative low scores of most states, states have a lot room for improvement in child care regulations.

HEALTH PROTECTION

Driver Safety--In the report, How State Laws Measure Up, states were scored based on six different categories. Overall, most states scored fair, with a mean score of 2. California received the best score while Montana received the worst score. While no state was ranked at a 4 "poor", it is apparent there is room for improvement.

Gun Control--Based on the Brady Campaign's state scorecard of 100 points, we ranked states 1 to 50 (Brady Campaign State Scorecard Rankings, 2008). California, with a score of 79, was ranked the best state while Oklahoma, Kentucky, and Louisiana placed last with a score of 2.

Emergency Preparedness--In terms of emergency preparedness, most states did fairly well, with more than 70% of states receiving a score of 7 or above on a scale of 1 to 10. Louisiana, New Hampshire, North Carolina, Virginia, and Wisconsin all received a perfect score of 10, while Arizona, Connecticut, Florida, Maryland, Montana, and Nebraska all received the lowest score of 5. While there is still room for improvement, it appears many states are well prepared for an emergency.

Rural Speed Limits--The mean for rural speed limits for all states was 70 mph, which is high compared to the lowest speed limit of 60 mph. A high percentage of states had high speed limits with 60% of states having a rural speed limit 70 mph or above. The state with the lowest rural speed limit of 60 mph was Hawaii, while there were several states with the highest speed limit of 75 mph.

Urban Speed Limits--The urban speed limits were lower than rural speed limits, with both the mean and median around 65 mph. In addition, 70% of the states had a speed limit of 65 mph or lower. Again, Hawaii had the lowest urban speed limit of 50 mph, while Idaho, North Dakota, and South Dakota, had the highest urban speed limit of 75 mph. While the urban speed limits are generally lower than the rural speed limits, there is still are large range among speed limits.

Fluoridation--States with the highest percentages of the population received fluoridated water received the highest rankings. Only 21 states are provided 80% or more of their populations with fluoridation. While some states such as Kentucky and Illinois have 99% of their populations received fluoridated water, states like Hawaii and Utah are provided less than 10%. As fluoridation is a critical factor in dental decay, many states should considered increasing fluoridation in their community water.

Public Health Funding--Only 12 states pro vided more than $100 per person for public health. Hawaii spent the most money, $198 per person, while Indiana spent the least amount of $33 per person. Public health funding is important to provide prevention and health promotion programs to citizens, and states who wish to promote the health of their population should be encouraged to provide sufficient funding to public health to serve these needs.

Mental Health Care Funding--In terms of per capita state spending on mental health in 2007, Alaska spent the most ($288 per capita), however, 70% of states spent $100 or less per capita on mental health. With the importance of mental health becoming more publicized, states may begin to acknowledge the importance of mental health spending.

ENVIRONMENT

Parks and Recreation Funding--Using information provided by the U.S. Census Bureau in 2000, states were ranked by their expenditure per capita on parks and recreation (State and Local Government Finances and Employment). About 75% of states spent $25 or less per capita. Kansas spent the least amount of $2 per capita while New Jersey had the highest per capita spending at $73. The wide range of per capita park and recreation spending noted suggests that many states might consider increased spending in this area.

Bike Friendliness--In terms of bike friendliness, Washington received the best score of 1 while West Virginia was ranked lowest.

State Environmental Output--Colorado ranked first while Oklahoma and Louisiana ranked last. To improve their score and the heath and quality of living for their citizenry some states should consider changing environmental policies.

Environmental Protection Programs--For environmental protection program spending, a wide range of spending among the states was noted, with 75% of states spending $50 or less per capita. Delaware spent the most ($288 per capita) while Nebraska, at least at the state level, spent $0 per capita on environmental protection programs.

Highway Spending--Overall, highway spending was fairly high with an average $105 per capita. Some states spent significantly more such as Minnesota ($250 per capita), while other states spent much less (West Virginia, $22 per capita). It is realized that the significant difference in range of per capita spending may be due to how states fund and organize their spending in this area.

ECONOMIC WELL-BEING

Education Spending--As with many other variables in this study, there was a large variability among education spending per capita among the states. While the average per capita spending was at $734 per capita, a quarter of the states spent less than $533 on a per capita basis. By far, the state that spent the highest amount was Hawaii ($1588), while New Hampshire spent $0 per capita.

Special Education--Overall, special education received a small amount of money from states with 80% of states spending less than $20 per capita. On average they spent $17 per capita. Some states such as New Mexico spent much more ($47) which others such as Nevada spent much less ($11).

Public Assistance--For public assistance, there was a wide variability among states per capita spending with Massachusetts spending highest at $200 and North Dakota lowest at $0 per capita. Spending was positively skewed as evidenced by a median per capita spending of $13 and mean per capita spending of $28. A quarter of the states spent less than $7 while only 10% of the states spent more than $60.

Minimum Wage--Only 10% of the states had a minimum wage of $8.00 or above. Washington had the highest minimum wage of $8.55, while the average minimum wage was $7.25. A minimum wage should not be confused with a living wage. A living wage is considerably higher than a minimum wage and is a term used to describe the minimum hourly wage necessary for shelter (housing and incidentals such as clothing and other basic needs) and nutrition for a person for an extended period of time. This standard generally means that a person working forty hours a week, with no additional income, should be able to afford a specified quality or quantity of housing food, utilities, transport, health care, and recreation food, utilities, transport, health care and recreation. In the U.S., the state of Maryland and several municipalities and local governments such as San Francisco, Santa Fe, Albuquerque and Washington, D.C. have enacted ordinances which set a minimum wage higher than the federal minimum for the purpose of requiring all jobs to meet the living wage for that region. States should evaluate their minimum wage to see if it can sufficiently provide living wage for residents.

Sales Tax--There was not a wide range of sales taxes and 70% of states had a sales tax of 6% or less. California had the highest sales tax (8%) while several states had the lowest (4%) such as Alabama, Georgia, and Wyoming.

RANKING BY CATEGORIES AND OVERALL RANKING

We also looked at the consistency of ranks across categories. State rankings by category and overall ranking are presented in Table 2.

A distinct variability among state rankings was noted. Among the top 10 states, only Vermont ranked in the top 10 in every category. All of the remaining top 10 states except Washington were among the top 10 in 3 categories. Of the bottom 10 ranked states, Nevada was the only state to be ranked in the bottom 10 for 3 of the 4 categories. Interestingly, Nevada ranked in the top 20 for the environmental category. Arizona, Idaho, Mississippi, Oklahoma, and Texas ranked in the bottom 10 for 2 categories.

When looking at the category rankings, no states except Vermont's category ranks were all in the same quintile (1-10, 11-20, 21-30, 31-40, 41-50). The majority of states were ranked in 3 or more quintiles, suggesting a wide variation in rankings among the states.

Some states did fairly well in some categories but poorly in another as well as vice versa. For example, Connecticut scored in the top 12 in health promotion, health protection, and economic well-being, but ranked 47th in environment. Wyoming scored in the bottom 10 for health promotion and economic well-being and 36th in health protection, but scored 2nd in environment. Some states had similar scores across categories, such as New Jersey which ranked between 5th and 13th.

While some trends among most categories were noted, this was not the case with environment. Several states such as Alabama, Wyoming, West Virginia, South Dakota, and Idaho had environmental ranks that differed significantly from their other rankings. For example, Idaho scored in the bottom 15 for economic well-being, health protection, and health promotion, but ranked in the top 20 for environment. On the other end, Alabama ranked in the top 25 for economic well-being, health promotion, and health protection, but ranked last in environment. This dissimilarity in environmental ranks suggests that states view these policies in different ways than other categories.

To obtain a different perspective of state ranking we utilized the data from Table 2 and applied GIS's ArcView to map each of the categories and overall ranking. Use of this software allows a visual and spatial presentation of the ranking data. These GIS mapping results are shown in Figures 1-5. Further reference to the GIS findings are presented later in this study.

RELATIONSHIPS BETWEEN CATEGORIES

To assess possible associations between categories, correlations were calculated based on the average score of each state in each category. A positive relationship would indicate that better ranked states (lower scores) on one category were also ranked better with lower scores on another category. Results are shown in Table 3.

Results from Table 3 indicate that health promotion is significantly correlated with health protection (p. <.01). It appears that policies in health promotion seem to carry over to health protection. Health promotion is also correlated, to a lesser extent, to economic well-being. Finally, health promotion is not significantly correlated with environment although there is a positive trend between the two categories.

Health protection is significantly correlated (p. <.01) with variables composing the economic wellbeing category but did not correlate with environment. That is, states that rank higher in economic support and policies for their population such as educational spending, a higher minimum wage, a less regressive (lower) sales tax and higher public assistance spending per capita also appear to rank higher in the health protection of its populace as indicated in policies such as gun control, drivers safety, emergency preparedness, fluoridation of water supplies as well as mental health and public health spending per capita. In contrast no significant correlation was found between health protection and environment thus suggesting that policies in environment do not carry over into economic policies conducive to population health.

There is no relationship between any of the categories and state population. That is, the size of the population does not appear to influence ranks in any categories. This is informative in that smaller states do not appear to be handicapped in any way by their population size.

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RESULTS BY POLITICAL PREFERENCE

Although not an intended purpose of this study, when looking over the maps we noticed a possible apparent association between state ranks and voting in the 2008 presidential election. To evaluate this, we correlated for which presidential candidate each state voted and their ranking in this study. Results appear to show that states that voted for the Democratic candidate (blue) have lower (better) ranks than those that voted for the Republican candidate (red). Furthermore, we performed a t-test on the comparison of state rankings and how states voted in that election. A significant difference (p. <.01) was noticed. "Democratic states" had an average rank of 12.1 while "Republican states" had a higher (worse) average rank of 36.2. Interestingly it was noted that 9 out of the 10 "best states" and 19 out of the top 20 states were those that had voted for the Democratic candidate. On the other hand, 9 out of the 10 of the worst ranked states voted Republican. These results suggest that political preference may influence health oriented policies.

CONCLUSIONS

Policies and regulations that encourage and maintain the health of residents are important. The lack of such policies and regulations can be hazardous to one's health. Using twenty-five public health population-based indicators, we ranked states in terms of how hazardous they are to population health. We not only provide an overall ranking of states but rankings for various categories including health promotion, health protection, the environment, and economic well-being. Overall, Delaware ranked best and Nevada worst. However, a wide variability of findings was noted not only between states but also between categories within states. Consistency in rankings between categories was elusive. While rankings between categories such as health promotion and health protection were noted, this was not the case for the categories of economic well-being and the environment. It seems that not only do states approach these categories differently but also differently within the states. Our findings suggest that rankings between states do not appear related to the size of state population. However, use of GIS mapping and subsequent statistical analysis evidenced a strong association between overall state rankings and voting results in the 2008 presidential election with Democratic voting states (blue) ranking more favorably than Republican voting states (red), indicating political orientation may be informative.

This study may provide useful information to a variety of stakeholders including policy makers, legislators and health professionals to develop and improve policies, regulations, health services, practices and the health status in their communities. The media may use these data to enhance the public's awareness of how well their state ranks in promoting the health and reducing hazards in their populations. Finally, individual citizens and organizations may find the ranking informative in efforts to improve community health.

ACKNOWLEDGEMENTS

The authors would like to thank the following individuals who composed the expert panel that provided suggestions and guidance for the variables used in this study: Beth Chaney, PhD, University of Florida; Lee Crandall, PhD, Clemson University; Gus Dalis, EdD, Los Angeles County Office of Education; James Eddy, DEd, University of North Carolina-Greensboro; David Macrina, PhD, University of Alabama at Birmingham; Julie A. Pryde, MSW, LSW, Champaign-Urbana Public Health Department, IL; David Remmert MPH, DeWitt-Piatt Bi-County Health Department, IL.

REFERENCES

American Lung Association. (2008). State of Tobacco Control 2008. Retrieved August 30, 2009 from http:// www.stateoftobaccocontrol.org/

The Brady Campaign. (2008). Brady Campaign State Scorecard Rankings. Retrieved August 30, 2009 from http://www.bradycampaign.org/stategunlaws/statescorecard

Carr, J. S. (2009), Study measures states by personal, economic freedoms. The Associated Press. Retrieved August 30, 2009 from http:// www.usatoday.com/printedition/n ews/20090323/freest ates23_st.art. htm

The Environmental Council of the States. (2008). State Environmental Budgets and Budget Plans, FY 2005-2008. Retrieved August 30, 2009 from http://www.ecos.org/files/3058_file_M arch_2008_ECOS_ Green_Report_Appendix.pdf

The Insurance Institute for Highway Safety. (2009, October) How State Laws Measures Up. August 30, 2009 from http://www.iihs.org/laws/measureup.aspx

The Insurance Institute for Highway Safety. (2009, October). Maximum Posted Speed Limit. Retrieved from August 30, 2009 from http://www.iihs.org/laws/speedlimits.aspx

The Kaiser Family Foundation. (2008). The Centers for Disease Control and Prevention (CDC) STD Prevention Funding, FY2007. Retrieved from August 30, 2009 from www.statehealthfacts.org. Data Source: National Alliance of State and Territorial AIDS Directors (NASTAD) at http://www.nastad.org, Special Data Request, 2008.

The Kaiser Family Foundation. (2008). Distribution of State General Fund Expenditures (in millions), SFY2007. Retrieved from August 30, 2009 from www.statehealthfacts.org Data Source: National Association of State Budget Officers. (2007). www.nasbo.org

League of American Bicyclists. (2009). 2009 State Rankings. Retrieved August 30, 2009 from http://www. bikeleague.org/programs/bicyclefriendlyamerica/bicyclefriendlystate/rankings.php

List, J., & McHone, W. (2000). Ranking State Environmental Outputs: Evidence from Panel Data. Growth & Change, 31(1), 23. Retrieved August 30, 2009 from http://search.ebscohost.com.proxy2.library.uiuc. edu

The National Association of Child Care Resource & Referral Agencies. (2007). We Can Do Better: NACCRRAs Ranking of State Child Care Stands and Oversight. Retrieved August 30, 2009 from http://www.naccrra. org/publications/naccrra-publications/we-can-do-better

National Conference of State Legislatures. (2005) Physical Education and Physical Activity for Children. Ncsl.org; Data Source: National Association for Sports & Physical Education; National Association of State Boards of Education; Trust for America's Health; Center for the Study of Social Policy; NIHCM Foundation.

The National Institute of Dental and Craniofacial Research. (2009, March) Community Water Fluoridation Status by State. Retrieved August 30, 2009 from www.nidcr.nih.gov/DataStatistics/FindDataByTopic/ Water Fluoridation/Community WaterFluoridationState.html. Data Source: Centers for Disease Control and Prevention 2002 Water Fluoridation Reporting System (WFRS).

Julia Hemphill, BS

Thomas O'Rourke, PhD, MPH, CHES

Blake Zachary, MHS

Julia Hemphill, BS, is in the Department of Kinesiology and Community Health at the University of Illinois. Thomas o'Rourke, PhD, MPH, CHES, is Professor Emeritus of Community Health at the University of Illinois. Blake Zachary, MHS. Please address all correspondence to Thomas O'Rourke, PhD., MPH, CHES, 1206. S. Fourth St., Rm. 129, University of Illinois, Champaign, IL 61820. Tel: (217) 840-7036. Fax: (217) 333-2766. E-mail: torourke@illinois.edu
Table 1. Population health results by category

Category & Variable                           Mean     Median

Health Promotion
  Tobacco Prevention Scoring(1-5)            4.58      5.00
  Beer Tax Per Pack                          $.28      $.19
  Immunization Percentage                    80.3%     80.1%
  STD Prevention Spending Per Capita         $.39      $.37
  Physical Education Requirements(1-6)       2.84      3.00
  Cigarette Tax Per Pack                     $1.29     $1.15
  Child Care Regulation Scoring(1-100)       57.5      55.46
Total Health Promotion                       -         -
  Drivers Safety Scoring(1-4)                2.08      2.17
  Gun Control Score(1-100)                   17.7      10.5
  Emergency Preparedness Scoring(1-10)       7.4       7.0
  Maximum Rural Speed Limit                  69.3      70.0
  Maximum Urban Speed Limit                  63.7      65.0
  Fluoridation Percentage                    67.2%     73.7%
  Public Health Spending Per Capita          $79.6     $72.0
  Mental Health Spending Per Capita          $89.95    $73.34
Total Health Protection                      -         -
Environment
  Park and Recreation Spending Per Capita    $19.05    $13.89
  Bike Friendly State Ranking(1-50)          na        na
  Environmental Output Ranking(1-47)         na        na
  Environmental Program Spending Per         $44.24    $34.13
Capita
  Highway Spending Per Capita                $118.69   $104.81
  Total Environmental                        -         -
  Economic Well-being
  Educational Spending Per Capita            $734.21   $703.78
  Special Education Spending Per Capita      $17.94    $16.86
  Public Assistance Spending Per Capita      $27.50    $13.01
  Minimum Wage                               $7.17     $7.25
  Sales Tax                                  6%        5.5%
  Total Economic Well-being                  -         -
  Overall Average                            -         -

Category & Variable                            Best &      Worst &
                                               State        State
Health Promotion
  Tobacco Prevention Scoring(1-5)            1(AK,DE)     5(AL (1))
  Beer Tax Per Pack                          $1.07(AK)    $0.02(WY)
  Immunization Percentage                    93.2%(NV)    66.7%(NV)
  STD Prevention Spending Per Capita         $.84(MD)     $.03(VA)
  Physical Education Requirements(1-6)       1(IL,NY)     6(CO,SD)
  Cigarette Tax Per Pack                     $3.46(RI)    $.07(SC)
  Child Care Regulation Scoring(1-100)       85(RI)       13(ID)
Total Health Promotion                       1(NY)        50(NV)
  Drivers Safety Scoring(1-4)                1(CA (2))    3(ID (3))
  Gun Control Score(1-100)                   79(CA)       2(KY (4))
  Emergency Preparedness Scoring(1-10)       10(LA (5))   5(AZ (6))
  Maximum Rural Speed Limit                  60(HI)       75(CO (7))
  Maximum Urban Speed Limit                  50(HI)       75(ID (8))
  Fluoridation Percentage                    99.6%(KY)    2.2%(UT)
  Public Health Spending Per Capita          $198(HI)     $33(IN)
  Mental Health Spending Per Capita          $288(AK)     $23(KS)
Total Health Protection                      1(HI)        50(ID)
Environment
  Park and Recreation Spending Per Capita    $73(NJ)      $2(KS)
  Bike Friendly State Ranking(1-50)          1(WA)        50(WV)
  Environmental Output Ranking(1-47)         1(CO)        47(OK)
  Environmental Program Spending Per         $228(DE)     $0(NE)
Capita
  Highway Spending Per Capita                $250(MN)     $22(WV)
  Total Environmental                        1(MN)        50(ID)
  Economic Well-being
  Educational Spending Per Capita            $1588(HI)    $0(NH)
  Special Education Spending Per Capita      $47(NM)      $11(NV)
  Public Assistance Spending Per Capita      $200(MA)     $0(CO (9))
  Minimum Wage                               8.55(WA)     2.65(KS)
  Sales Tax                                  2%(DE)       8%(CA)
  Total Economic Well-being                  1(AK)        50(SC)
  Overall Average                            1(DE)        50(NV)

(1) More than one state: AL, AR, AZ, CA, CT, FL, GA, ID, IL,IN, IA, KS,
KY, LA, MD, MA, MI, MN, MS, MO, NE, NV, NH, NJ, NM, NY, NJ, NC, ND,
OH, OK, OR, PA, RI, SC, TN, TX, UT, VA, WA, WV, WI

(2) CA, GA, LA, MD, NJ, OR, TN

(3) ID, IA, MS, MO, MT, NH, ND, PA, SC, SD, WY

(4) KY, LA, OK

(5) LA, NH, NC, VA, WI

(6) AZ, CT, FL, MD, MT, NE

(7) AZ, CO, ID, MT, NE, NV, NM, ND, OK, SD, TX, UT, WY

(8) ID, NM, ND, SD

(9) CO, LA, ND, WY

Na--only ranks available

Table 2. State rankings by category and overall ranking

State             Health       Health     Environment
                 Promotion   Protection

Alabama             22           16           50
Alaska               8           14            6
Arizona             38           41           37
Arkansas            44           34           43
California          41           12           26
Colorado            42           30           21
Connecticut          7           12           47
Delaware             2           3            12
Florida             15           44           20
Georgia             32           22           42
Hawaii               5           1            10
Idaho               48           50           19
Illinois            11           8            14
Indiana             45           21           24
Iowa                39           25           23
Kansas              35           49           33
Kentucky            46           31           41
Louisiana           40           35           25
Maine               10           28           12
Maryland             3           4            36
Massachusetts       13           10           31
Michigan            19           20           15
Minnesota           28           18            1
Mississippi         34           43           29
Missouri            49           33           27
Montana             28           48           40
Nebraska            29           40           28
Nevada              50           46           18
New Hampshire       21           29            8
New Jersey           6           9             5
New Mexico          19           39           44
New York             1           5            18
North Carolina      16           28           16
North Dakota        20           37           34
Ohio                25           26           45
Oklahoma            23           42           49
Oregon              36           23            7
Pennsylvania        24           13           33
Rhode Island         9           6            22
South Carolina      26           32           35
South Dakota        14           38            4
Tennessee           17           15           30
Texas               33           45           48
Utah                37           47           39
Vermont              4           7             3
Virginia            43           2            38
Washington          12           19            9
West Virginia       30           24           46
Wisconsin           31           17           12
Wyoming             47           36            2

State             Economic    Overall
                 Well-being

Alabama              24         31
Alaska               1           4
Arizona              46         47
Arkansas             28         40
California           15         21
Colorado             39         33
Connecticut          6          12
Delaware             10          1
Florida              40         34
Georgia              27         28
Hawaii               12          5
Idaho                36         49
Illinois             31         10
Indiana              38         29
Iowa                 22         27
Kansas               20         44
Kentucky             18        35.5
Louisiana            45         38
Maine                3           8
Maryland             42         13
Massachusetts        5          11
Michigan             34         16
Minnesota            32         14
Mississippi          49         46
Missouri             23         39
Montana              19         42
Nebraska             17        35.5
Nevada               47         50
New Hampshire        44         19
New Jersey           13          6
New Mexico           2          25
New York             4           3
North Carolina       33         18
North Dakota         43         37
Ohio                 36         32
Oklahoma             21         45
Oregon               7          15
Pennsylvania         31         22
Rhode Island         8           7
South Carolina       50         41
South Dakota         26         23
Tennessee            48         24
Texas                36         48
Utah                 14         43
Vermont              9           2
Virginia             29         20
Washington           16          9
West Virginia        12         26
Wisconsin            25         17
Wyoming              41         30

Table 3. Correlations of Categories

               Health      Health       Environment
               Promotion   Protection

Health         1.00        .56 *        .25
Promotion
Health         .56 *       1.00         .26
Protection
Environment    .25         .26          1.00
Economic       .41 *       .37 *        .08
Well-being
2008           .03         -.17         .12
Population
State Voting   -.39 *      -.59 *       -.41 *

               Economic     2008         State
               Well-being   Population   Voting

Health         .41 *        .03          -.39 *
Promotion
Health         .37 *        -.17         -.59 *
Protection
Environment    .08          .12          -.41 *
Economic       1.00         .07          -.23
Well-being
2008           .07          1.00         .24
Population
State Voting   -.23         .24          1.00

* p-value < .01
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