Theis, Lindsey
Planalp, Colin

Measuring State-level Disparities in Unhealthy Days (infographics)

Although health disparities in the United States have been common knowledge among public health professionals for years, the COVID-19 pandemic highlighted this problem with vivid urgency. The disproportionate impact of the pandemic on certain segments of the population—such as higher infection and death rates among Black people and American Indian and Alaska Native people—isn’t an aberration but rather a consequence of systems that fail many communities. Health inequities run wide and deep in the U.S., extending far beyond COVID into other areas of physical and mental health.

Another issue the pandemic has highlighted is the enormous power that states have to influence health policy, as shown recently by mask and vaccination requirements instituted by some states—and prohibited by others. As the pandemic wanes, states will have a new opening to exercise their powers to tackle health inequities.

To help policymakers and other stakeholders identify opportunities to improve health equity in their states, SHADAC has produced a set of data resources for the 50 states and the District of Columbia. Using the Behavioral Risk Factor Surveillance System (BRFSS) Survey—combining the three most recent years of data (2018-2020) to improve our ability to develop reliable state-level estimates for smaller population subgroups—we created both maps and charts that show how states compare to the U.S. average in measures of people’s self-reported physical and mental health, and how people’s physical and mental health varies depending on their race and ethnicity, level of income, and age within each state.

Click any state below to view its factsheet or click here to download a PDF of this blog and all state factsheets.

State physical and mental health
To assess how state residents’ physical and mental health matches up against the U.S. overall, SHADAC used statistical testing to compare the average number of days in the prior month that adults in each state report their physical or mental health was “not good” versus the average number for the same metric across the entire U.S.

Physical health
Among the states, 19 had an average number of physically unhealthy days that was better (i.e., lower) than the U.S. average of 3.8 days per month. Meanwhile, 20 states had an average number of physically unhealthy days that was worse (i.e., higher) than the U.S. average. The remaining 12 states had average numbers of physically unhealthy days that were not significantly different from the U.S. rate.

The District of Columbia reported the lowest average number of physically unhealthy days per month, at 3.0 days, while West Virginia reported the highest average number, at 5.5 days—a difference of two and a half extra days.

Mental health
For mental health, 17 states had an average number of unhealthy days that was better (i.e., lower) than the U.S. average of 4.2 days per month. Meanwhile, 19 states had an average number of mentally unhealthy days that was worse (i.e., higher) than the U.S. average. The remaining 15 states had average numbers of mentally unhealthy days that were not significantly different from the U.S. rate.

South Dakota reported the lowest average number of mentally unhealthy days per month, at 3.3 days, while West Virginia again reported the highest average number, at 5.7 days—a difference of almost two and a half extra days.

In addition to considering them separately, we also found substantial overlap in the states with mentally and physically unhealthy days that were significantly different from the U.S. average: 15 states had average numbers of unhealthy days that were better than the U.S. average for both physical and mental health, and 16 states had average numbers of unhealthy days that were worse than the U.S. average for both.

However, there were examples in which states demonstrated distinct differences. For instance, Utah and the District of Columbia both had physically healthy days that were significantly lower than the U.S. average, while their mentally unhealthy days were significantly higher than the U.S. average.

Physical and mental health inequities
While the dynamics vary state-to-state, physical and mental health data at the national level demonstrate clear inequities by demographics, including race and ethnicity, income, and age.

Race and ethnicity
Physical health
For the total U.S. population, the self-reported average of physically unhealthy days was 3.8 per month. This number varied across racial and ethnic population subgroups, with some clear health disparities—a finding that is consistent with other evidence of pervasive health inequities influenced by conditions such as discrimination and social risk factors, including lower incomes and limited access to health care.¹

Asian and Pacific Islander people reported the lowest number of physically unhealthy days, at 2.0 days per month, which was significantly lower than the total population. Hispanic people also reported physically unhealthy days that were significantly lower than the total population, at 3.6 days per month.

American Indian and Alaska Native people reported the highest number of physically unhealthy days, at 5.9 days per month, which was significantly higher than the total population rate. Black people and White people reported average physically unhealthy days that were only slightly higher than the total population, at 3.9 days and 3.8 days per month, though those small differences were still significantly different.² People reporting Any other race or multiple races also reported physically unhealthy days that were significantly higher than the total population, at 4.7 days per month.

Mental health
The pattern for mentally unhealthy days by race and ethnicity was similar to that for physically unhealthy days. For the total U.S. population, people reported an average of 4.2 mentally unhealthy days per month. Asian and Pacific Islander people reported the lowest number of mentally unhealthy days, at 2.8 days per month, which was significantly lower than the total population. Hispanic people also reported mentally unhealthy days that were significantly lower than the total population, at 4.0 days per month.

People reporting Any other race or multiple races reported the highest average number of mentally unhealthy days, at 5.9 days per month, which was significantly higher than the total population. American Indian and Alaska Native people reported the second-highest number of mentally unhealthy days, at 5.7 days per month, which again was significantly higher than the total population rate. Black people and White people reported average mentally unhealthy days that were only slightly higher than the total population, at 4.4 days and 4.3 days per month—seemingly small differences that were nevertheless statistically significant.

Income
Physical health
For the U.S. population, self-reported physical health was worse among people with lower incomes and better among people with higher incomes—an unsurprising finding, as income is associated with many factors related to health. For instance, people with lower incomes are more likely to live with poor air quality, as highways and industrial facilities that produce pollution tend to be found nearer to low-income housing.^3,4 And people with higher incomes are more likely to have both health insurance and easier access to health care.⁵

People with incomes of $75,000 or more (the highest category in our analysis), reported the lowest average number of physically unhealthy days, at 2.1 per month. Furthermore, the average number of physically unhealthy days reported by individuals increased as their incomes decreased, with those in the $50,000 to $74,999 income category reporting 3.0 days per month. Both of those were significantly lower than the total U.S. population rate of 3.8 physically unhealthy days per month.

People with the lowest incomes (below $25,000), reported the highest average number of physically unhealthy days at 6.4 days per month—a figure roughly two and a half days higher than the total U.S. population and a statistically significant difference. Those with incomes between $25,000 and $49,999 reported 3.9 physically unhealthy days per month, which was just slightly higher than the total U.S. population number of 3.8 days, though the difference was still statistically significant.

Mental health
The overall pattern for self-reported mentally unhealthy days by income was almost identical to that for physically unhealthy days. People with the highest ($75,000 and higher) and next-highest ($50,000 to $74,999) incomes reported the lowest average mentally unhealthy days, at 3.0 and 3.8 days per month, respectively. Both were significantly lower than the average number of mentally unhealthy days for the U.S. population, at 4.2 per month.

People with the lowest incomes (less than $25,000) reported the highest number of mentally unhealthy days, at 6.3 days per month. That was roughly two additionally mentally unhealthy days compared to the total population average, a statistically significant difference. People with the next-lowest incomes ($25,000 to $49,999), reported an average of 4.5 mentally unhealthy days per month, which also was significantly higher than the total population average.

Age
Physical health
For the U.S. population, the number of self-reported physically unhealthy days increased along with age, a finding that is consistent with the fact that many common chronic health issues—such as heart disease and diabetes—are more prevalent among the older population.

Adults age 65 and over (“older adults”) reported the highest average number of physically unhealthy days, at 5.1 days per month, which was more than one day over the total U.S. population average of 3.8 days—a statistically significant difference. Adults age 40-64 (“middle-aged adults”) also reported an average number of physically unhealthy days that were significantly higher than the total U.S. population average, at 4.3 days per month. Meanwhile, adults age 18-39 (“younger adults”) reported the lowest average number of physically unhealthy days, at 2.4 days per month, which was almost two and a half fewer days than the total U.S. average—a statistically significant difference.

Mental health
In contrast with physically unhealthy days, the pattern for mentally unhealthy days by age was reversed: Average mentally unhealthy days declined as age increased. Though this pattern may be surprising to those unfamiliar with issues of mental health, it is consistent with other evidence, such as data from the National Survey on Drug Use and Health (NSDUH), which finds that mental illness is roughly twice as common among adults 25 years and younger as compared to adults age 50 and older.⁶

Younger adults reported the highest average number of mentally unhealthy days per month, at 5.3 days. That number was roughly one day more than the total U.S. population rate of 4.2 days, a statistically significant difference. Meanwhile, older adults reported an average of 2.6 mentally unhealthy days per month, roughly one and a half fewer days than the overall U.S. population, and middle-aged adults reported an average of 4.1 mentally unhealthy days per month, which was only slightly lower than the overall population, but still a statistically significant difference.

Conclusion
Understanding how individuals’ self-reported mental and physical health vary across the states and by subpopulation at the national level offers one approach to identifying broad health inequities. Comparing the average number of physically and mentally unhealthy days for state residents against the U.S. average can allow states to identify widespread gaps. And within their populations, those same data offer states an opportunity to identify more specific health inequities. At the U.S. level, data show that certain demographic groups experience worse health. For instance, American Indian and Alaska Native people on average report significantly worse mental and physical health, as do people with lower incomes. Meanwhile, younger adults report significantly worse mental health, while older adults report significantly worse physical health. The state-level data SHADAC has published in this resource provides states with an ability to examine health inequities for their particular populations.

Click here to download this blog, data tables, and all state factsheets.