17 

Introduction 

About the Project 

The Appalachian Region 

Visualization of the Health Measures: Quintiles, 

Thematic Maps, and Box Plots 
18 
CREATING A CULTURE OF 

HEALTH IN APPALACHIA Introduction | HEALTH DISPARITIES

19 

ABOUT THE PROJECT 

Culture of Health 

Creating a Culture of Health in Appalachia: Disparities and Bright Spots is an innovative research 

initiative sponsored by the Robert Wood Johnson Foundation (RWJF) and the Appalachian Regional 

Commission (ARC) and administered by the Foundation for a Healthy Kentucky. This multi-part health 

research project will, in successive reports: measure population health and document health disparities in 

the Appalachian Region; establish a framework for identifying Appalachian “Bright Spots,” or 

communities with better-than-expected health outcomes, including factors that reflect a Culture of Health; 

and, through in-depth case studies, explore replicable activities, programs, or policies that encourage 

better-than-expected health outcomes that translates into actions that other communities could replicate. 

The Robert Wood Johnson Foundation’s vision for a national Culture of Health—enabling all in our 

diverse society to lead healthier lives—is based on ten underlying principles: 

1. Good health flourishes across geographic, 

demographic, and social sectors. 

6. Everyone has access to affordable, quality 

health care. 

2. Attaining the best health possible is valued 

by our entire society. 

7. Health care is efficient and equitable. 

3. Individuals and families have the means 

and the opportunity to make choices. 

8. The economy is less burdened by 

excessive and unwarranted health care 

spending. 

4. Business, government, individuals, and 

organizations work together to build 

healthy communities. 

9. Keeping everyone as healthy as possible 

guides public and private decisionmaking. 

5. No one is excluded. 10. Americans understand that we are all in 

this together. 

According to the Robert Wood Johnson Foundation, building a Culture of Health means creating a 

society that gives every person an equal opportunity to live the healthiest life they can—whatever their 

ethnic, geographic, racial, socioeconomic, or physical circumstances happen to be. A Culture of Health 

recognizes that health and well-being are greatly influenced by where we live, how we work, the safety of 

our surroundings, and the strength and connectivity of our families and communities—and not just by 

what happens in the doctor's office. 

Overview of Health Measures 

The 41 measures featured in this report provide a comprehensive picture of health in the Appalachian 

Region, focusing on how the Region compares to the United States as a whole and how parts of the 

Region compare to one another. This report uses a diverse group of measures that consider: disease 

outcomes, the health of children and adults, the health care delivery system, the quality of care, and social 

determinants—providing a broad understanding of population health in Appalachia. 

The ten principles and the four Action Areas associated with RWJF’s Culture of Health served as a 

starting point for identifying appropriate measures that reflect health outcomes and factors that drive or 
CREATING A CULTURE OF 

HEALTH IN APPALACHIA Introduction | HEALTH DISPARITIES

20 

influence overall health in the Appalachian Region. Many of the measures in this report were chosen to 

reflect the RWJF Culture of Health Action Areas framework shown in Figure 2 (Plough, 2015). 

All measures are presented in a national context to align with ARC’s vision for bringing the Appalachian 

Region to parity with the nation. By establishing baselines of national and Appalachian performance for a 

number of health-related measures, this report provides a reference point to not only understand 

population health in the Appalachian Region, but also to support the development of a statistical 

framework for identifying Bright Spots. 

Figure 2: Robert Wood Johnson Foundation Culture of Health Action Areas

The measures of health in this report are organized into domains by common characteristics—capturing a 

cross section of factors that contribute to population health. Grouping the measures into domains allows 

the reader to identify and explore themes among related measures more easily. There are nine domains: 

Mortality, Morbidity, Behavioral Health, Child Health, Community Characteristics, Lifestyle, Health 

Care Systems, Quality of Care, and Social Determinants. 

The measures in the Mortality domain examine cause-specific deaths within a population and also include 

a broad measure of premature mortality. The indicators in the Morbidity domain explore physical health 

through the prevalence of disease and other health conditions, while mental health is examined through 

the measures in the Behavioral Health domain related to both mental health and substance abuse. 

Circumstances surrounding birth are explored in the Child Health domain. Individual choices and habits 

play an important role in the health of a population—these are examined by the measures in the Lifestyle 
CREATING A CULTURE OF 

HEALTH IN APPALACHIA Introduction | HEALTH DISPARITIES

21

domain. The Culture of Health framework recognizes that the environment in which an individual lives 

and works is important to health—the measures included in the Community Characteristics domain 

examine aspects of the external environment that are largely outside of residents’ control, while the 

conditions in which people live and work are explored in the Social Determinants domain. The 

comprehensiveness of available care is represented by the Health Care Systems domain which includes 

measures related to the availability of, and access to, healthcare, and by the Quality of Care domain, 

which measures the types of care that are available to a community. 

Within each domain, measures either describe a health outcome or are factors that drive health outcomes

(see Table 11). This distinction is important for structuring the framework in the subsequent Bright Spots 

analysis. 

Outcomes are conditions or events that reflect health status. Examples of outcomes in this report include 

mortality rates, incidence of disease, and percentages of a population experiencing depression or 

substance abuse. 

Drivers, often referred to as health determinants, are measures that impact health status and can be 

socioeconomic, behavioral, environmental, or associated with the quality of the health care system. For 

example, income and educational attainment have long been linked to overall health status. Some drivers, 

such as the supply of mental health providers, may impact outcomes in a specific domain, such as 

Behavioral Health.

Measures included in this report had to meet four criteria: 

• Available to the public (including those for which permission must be obtained);

• Calculated at the county level and available for nearly all counties in the U.S.;

1

• Relevant to the overall concept of population health; and

• Fit within one of the domains.

Despite their importance in understanding population health, a number of measures could not be included 

in this report due to lack of availability. Although oral health has a well-documented effect on both the 

physical and mental health of individuals, there is no readily obtainable data source for all counties in the 

United States. Likewise, Hepatitis C prevalence was excluded for lack of uniform availability at the

county level.

Compiled data for the 41 indicators included in this report are available in the accompanying file, 

Appalachian_Health_Disparities_Data.xlsx.

 1 Some intra-county smoothing is required in counties with small sample sizes for certain measures. See Appendix B for details.
CREATING A CULTURE OF 

HEALTH IN APPALACHIA Introduction | HEALTH DISPARITIES

22 

Table 11: Health Measures, by Domain 

Domain Measure Outcome 

/ Driver Domain Measure Outcome / Driver 

Mortality 

Heart Disease 

Deaths Outcome 

Lifestyle 

Physical Inactivity Driver 

Cancer Deaths Outcome Smoking Driver 

COPD Deaths Outcome Chlamydia Incidence Driver 

Injury Deaths Outcome 

Health Care 

Systems 

Primary Care 

Physicians Driver 

Stroke Deaths Outcome Mental Health 

Providers Driver 

Diabetes Deaths Outcome Specialty Physicians Driver 

Years of Potential 

Life Lost Outcome Dentists Driver 

Morbidity 

Physically Unhealthy 

Days Outcome Uninsured Population Driver 

Mentally Unhealthy 

Days Outcome Heart Disease Hospitalizations Outcome 

HIV Prevalence Outcome COPD 

Hospitalizations Outcome 

Diabetes Prevalence Outcome 

Quality of 

Care 

Electronic 

Prescribing Driver 

Adult Obesity 

Prevalence Outcome Mammogram Screenings Driver 

Behavioral 

Health 

Depression 

Prevalence Outcome Diabetes Monitoring Driver 

Suicide Outcome 

Social 

Determinants 

Median Household 

Income Driver 

Excessive Drinking Outcome Poverty Driver 

Poisoning Deaths Outcome Disability Driver 

Opioid Prescriptions Outcome Education Driver 

Child Health 

Infant Mortality Outcome Social Associations Driver 

Low Birth Weight Outcome 

Teen Birth Rate Driver 

Community 

Characteristics 

Travel Time to Work Driver 

Grocery Store 

Availability Driver 

Student–Teacher 

Ratio Driver 

 
CREATING A CULTURE OF 

HEALTH IN APPALACHIA Introduction | HEALTH DISPARITIES

23 

As noted before, some of the indicators also directly reflect one of the four Culture of Health Action 

Areas (shown in Table 12). 

Table 12: Health Measures, by RWJF Culture of Health Action Area 

RWJF Culture of Health Action Area Measure of Health 

1. Making Health a Shared Value Infant Mortality, Teen Births, Physical Inactivity, 

Chlamydia Rate 

2. Fostering Cross-Sector Collaboration 

to Improve Well-Being 

Electronic Prescriptions, Mammogram Screenings, 

Poverty, Social Associations 

3. Creating Healthier More Equitable 

Communities 

Depression, Opioid Prescriptions, Student-Teacher 

Ratio, Primary Care Physicians 

4. Strengthening Integration of Health 

Services and Systems 

Heart Disease Hospitalizations, Uninsured Population, 

COPD Hospitalizations 

Previous Research on Health Disparities in Appalachia 

The term health disparity refers to a difference in a health outcome across subgroups of a population; the 

literature contains many variations of this general idea (Elimination of Health Disparities, 2014). The 

Centers for Disease Control and Prevention (CDC) defines health disparities as gaps in health 

determinants or outcomes between different segments of a population (Centers for Disease Control and 

Prevention, What are Health Disparities?, 2013). The U.S. Department of Health and Human Services 

defines health disparities as “differences in health outcomes that are closely linked with social, economic, 

and environmental disadvantage” (United States Department of Health and Human Services, 2012). 

Healthy People 2020 defines health disparities similarly (Healthy People 2020, 2017). 

The October 2006 issue of CDC’s journal, Preventing Chronic Disease, featured a series of articles 

exploring challenges related to cancer prevention and treatment in the Appalachian Region. (Centers for 

Disease Control and Prevention, Preventing Chronic Disease: Appalachian Health, 2006). One article 

discussed the challenges of evaluating health disparities in the Appalachian Region (Behringer & Friedell, 

2006). The article noted that, prior to 2006, outcome data for small areas within the Region were difficult 

to obtain. However, after electronic reporting systems improved data capabilities, examination of these 

data showed that outcomes in Appalachia were much poorer than outcomes in the rest of the nation. The 

report cites higher rates of cervical cancer, heart disease, and premature death in the Region. 

A 2010 study completed by researchers at the University of Virginia concluded that persons living in 

communities in Appalachian Virginia were not receiving adequate healthcare relative to non-Appalachian 

Virginia counties, regardless of health insurance status (McGarvey, Leon-Verdin, Killos, Guterbock, & 

Cohn, 2011). 
CREATING A CULTURE OF 

HEALTH IN APPALACHIA Introduction | HEALTH DISPARITIES

24 

The Appalachian Regional Commission has commissioned several studies on health and health disparities 

in Appalachia. 

A seminal report published in 2004 established a baseline regarding health disparities in the Region and 

compared Appalachia to the non-Appalachian United States (Halverson, Ma, & Harner, 2004). The 

authors concluded that the Region as a whole suffered considerable excess mortality from leading causes 

of death when compared to the rest of the nation. Halverson et al. also found a high degree of variability 

within the Region in various measures of mortality and rates of hospitalization. The report found that the 

most adverse outcomes were correlated with socioeconomic characteristics, behavioral risk profiles, and 

available medical resources, all of which vary greatly across geographies. However, the report established 

no statistical relationship between any of the explanatory factors and outcomes; many of the disparities 

were thus deemed variable and localized in nature. 

Mental health and substance abuse, as well as access to treatment in the Appalachian Region were 

analyzed in a 2008 report (National Opinion Research Center (NORC) at the University of Chicago, and 

East Tennessee State University, 2008). This report found that disparities do exist in the Region for 

specific substance abuse issues and mental health conditions. 

A 2012 report measured disparities in healthcare cost and access concluded that Appalachian counties lag 

behind non-Appalachian counties in both of these areas. This research also suggested a cultural, uniquely 

Appalachian factor with regard to health status—one that transcends economic status (Lane, Lutz, & 

Baker, 2012). 
CREATING A CULTURE OF 

HEALTH IN APPALACHIA Introduction | HEALTH DISPARITIES

25 

THE APPALACHIAN REGION 

This report explores health disparities by geography and economic status across the Appalachian Region. 

Specifically, the report focuses on the difference between the Region and the United States as a whole; 

differences across Appalachian subregions; differences between the Appalachian and non-Appalachian 

portions of the states in the Region; differences based on rurality; and differences based on economic 

status. Exploring the data in different ways—such as using these various geographies—grants an 

additional lens to examine health in the Region. 

Geographic Subregions 

The current boundary of the Appalachian Region includes all of West Virginia and parts of 12 other 

states: Alabama, Georgia, Kentucky, Maryland, Mississippi, New York, North Carolina, Ohio, 

Pennsylvania, South Carolina, Tennessee, and Virginia. The Region is home to more than 25 million 

people and covers 420 counties and almost 205,000 square miles. 

The Appalachian subregions are nearly contiguous regions of relatively similar characteristics 

(topography, demographics, and economics) within Appalachia (see Figure 3). Originally consisting of 

three subregions, ARC revised the classification system in 2009 and now divides the Region into five 

subregions. These smaller areas, the boundaries of which are based on recent economic and transportation 

data, allow for greater analytical detail. 

Figure 3: Appalachian Subregions 

Source: Appalachian Regional Commission, Created November 2009

GEORGIA

ALABAMA

MISSISSIPPI

SOUTH

CAROLINA

NORTH CAROLINA

VIRGINIA

WEST

VIRGINIA

KENTUCKY

OHIO ILLINOIS INDIANA

WISCONSIN

MICHIGAN

DE

NJ

PENNSYLVANIA

MARYLAND

NEW YORK

TENNESSEE

0 1 50 00

Miles

Northern

North Central

Central

South Central

Southern

Subregions
CREATING A CULTURE OF 

HEALTH IN APPALACHIA Introduction | HEALTH DISPARITIES

26 

Rurality in Appalachia 

ARC, in coordination with staff at USDA’s Economic Research Service (ERS) developed a simplified 

version of the 2013 Urban Influence Codes (UIC) to distinguish metropolitan counties by population size 

of their metro area, and nonmetropolitan counties by the size of their largest city or town, as well as 

proximity to metro areas. ARC simplified the original 12-part county classification into five levels: large 

metropolitan area, small metropolitan area, non-metropolitan area adjacent to a large metropolitan area, 

non-metropolitan area adjacent to a small metropolitan area, and rural area. Figure 4 displays Appalachian 

counties by level of rurality. 

Appalachia has 37 large metro counties, 115 small metro, 44 non-metro adjacent to large metro, 117 nonmetro adjacent to small metro counties, and 107 rural counties. 

Figure 4: Rurality by County in Appalachia 

Source: USDA, Economic Research Service, 2013 Urban Influence Codes. Condensed by ARC. Figure created by ARC, October

2016.

GEORGIA

ALABAMA

MISSISSIPPI

SOUTH

CAROLINA

NORTH CAROLINA

VIRGINIA

WEST

VIRGINIA

KENTUCKY

OHIO ILLINOIS INDIANA

WISCONSIN

MICHIGAN

DE

NJ

PENNSYLVANIA

MARYLAND

NEW YORK

TENNESSEE

0 50 100

Miles

Large Metros (pop. 1 million +)

Small Metros (pop. <1 million)

Nonmetro, Adjacent to Large Metros

Nonmetro, Adjacent to Small Metros

Rural (nonmetro, not adj. to a metro)

Rural-Urban CountyTypes
CREATING A CULTURE OF 

HEALTH IN APPALACHIA Introduction | HEALTH DISPARITIES

27 

County Economic Status in Appalachia 

ARC also classifies counties based on economic status. The following information is based on ARC’s 

report, “County Economic Status in Appalachia, FY 2017.” Figure 5 shows Appalachian counties by 

economic status for fiscal year 2017. 

The Appalachian Regional Commission uses an index-based county economic classification system to 

identify and monitor the economic status of Appalachian counties. The system involves the creation of a 

national index of county economic status through a comparison of each county's averages for three 

economic indicators—three-year average unemployment rate, per capita market income, and poverty 

rate—with national averages. The resulting values are summed and averaged to create a composite index 

value for each county. Each county in the nation receives a rank based on its composite index value, with 

higher values indicating higher levels of distress. 

Each Appalachian county is classified into one of five economic status designations, based on its position 

in the national ranking. 

Distressed 

Distressed counties are the most economically depressed counties. They rank in the worst 10 percent of 

the nation's counties. 

At-Risk 

At-Risk counties are those at risk of becoming economically distressed. They rank between the worst 10 

percent and 25 percent of the nation's counties. 

Transitional 

Transitional counties are those transitioning between strong and weak economies. They make up the 

largest economic status designation. Transitional counties rank between the worst 25 percent and the best 

25 percent of the nation's counties. 

Competitive 

Competitive counties are those that are able to compete in the national economy but are not in the highest 

10 percent of the nation's counties. Counties ranking between the best 10 percent and 25 percent of the 

nation's counties are classified competitive. 

Attainment 

Attainment counties are the economically strongest counties. Counties ranking in the best 10 percent of 

the nation's counties are classified attainment. 

A sixth category—Non-Distressed— is used throughout this report to separate counties in the Distressed 

category from the other categories: 

Non-Distressed 

This category includes all counties in the four classifications outside of the Distressed designation: AtRisk, Transitional, Competitive, and Attainment. 
CREATING A CULTURE OF 

HEALTH IN APPALACHIA Introduction | HEALTH DISPARITIES

28 

Figure 5: County Economic Status in Appalachia, FY 2017 

 
CREATING A CULTURE OF 

HEALTH IN APPALACHIA Introduction | HEALTH DISPARITIES

29 

VISUALIZATION OF THE HEALTH MEASURES: QUINTILES, THEMATIC MAPS, 

AND BOX PLOTS 

For the 41 indicators, this report uses the values for the national quintiles for each measure and classifies 

each Appalachian county into one of these five groups. In addition to maps displaying the county-level 

values for the Appalachian Region and the United States, each indicator has accompanying charts and 

graphs displaying data for: the Region compared both to the U.S. as a whole and to the non-Appalachian 

portion of the country; the Appalachian subregions; Appalachian levels of rurality; and Appalachian 

economic status levels. State-level aggregation is done at three levels: the entire state, and then both the 

Appalachian and non-Appalachian portions of each state. 

 

Although national quintiles provide a first look at how Appalachia is doing when compared to the nation 

as a whole, providing data for the rest of the nation as well as by subregion, level of rurality, and 

economic status grants an additional comparative viewpoint to examine health throughout the Region. 

 

Quintiles 

The data in this report are broken down by national quintiles, which are groups of data points that have 

been divided into five equal parts consisting of approximately the same number of counties in each. The 

quintiles are calculated from national datasets and are thus based on the national distributions for each 

measure. The first quintile represents data points in the 20th percentile and below, the second quintile 

represents data points between the 20th and 40th percentiles, and so on. If the Appalachian Region’s 

distribution matched the national distribution, each Appalachian quintile would contain 84 counties (20 

percent of the total counties in Appalachia). Organizing the data into quintiles provides insight into how 

county-level outcomes are distributed throughout the Region, and can also help answer the question as to 

whether outcomes in the Appalachian Region are proportional to the outcomes in the nation as a whole. 

Table 13 shows the distribution of cancer mortality rates for Appalachian counties among national 

quintiles. Of the 420 counties in the Appalachian Region, 158 counties (38 percent) have cancer mortality 

rates in the worst-performing national quintile, while only 29 counties in the Region (7 percent) are in the 

best-performing national quintile. If the Appalachian distribution matched the nation’s, there would be 84 

counties (20 percent) in each quintile. This distribution shows that cancer mortality rates are 

disproportionately higher (worse) throughout the Appalachian Region when compared to the nation as a 

whole. 

Table 13: Distribution of Cancer Mortality Rates per 100,000 Population among National Quintiles 

for Appalachian Counties 

Indicator 

Best 

Quintile 

2nd Best 

Quintile 

Middle 

Quintile 

2nd Worst 

Quintile 

Worst 

Quintile 

 # Pct. # Pct. # Pct. # Pct. # Pct. 

Cancer deaths 29 7% 49 12% 83 20% 101 24% 158 38% 

Data source for authors’ calculations shown above: Appalachian_Health_Disparities_Data.xlsx. The number of counties across 

all five quintiles for each indicator may not sum to 420 due to missing or suppressed values. 
CREATING A CULTURE OF 

HEALTH IN APPALACHIA Introduction | HEALTH DISPARITIES

30 

Thematic Maps 

This report contains two maps for each indicator—one for the Appalachian Region and another for the 

entire United States, with the Region highlighted in orange. Each map color codes all counties into five 

national quintiles, each containing 20 percent of the nation’s counties. Throughout the report, darker 

colors represent less desirable results (i.e., results associated with worse health). For example, in the maps 

showing cancer mortality, the darkest blue counties have the highest cancer mortality rates and rank in the 

worst-performing national quintile while the lightest counties have the lowest cancer mortality rates and 

rank in the best-performing national quintile. It is important to note that the five groupings in the 

Appalachian maps are based on these national quintiles. That is, there are an equal number of counties 

with each color in the national map.2

 Because the regional map is also based on national quintiles, unless 

the Appalachian distribution matches the national distribution, the Region will almost always have more 

of some colors than of others. 

Figure 6 presents a map of cancer mortality rates per 100,000 population in the Appalachian Region. The 

upper left of the figure shows the legend containing the national quintile ranges. The worst-performing 

quintile is the darkest shade of blue, and has values ranging from 200 to 394 deaths per 100,000 

population. A review of the Appalachian map shows that counties in the Central and North Central 

subregions (Appalachian Kentucky, Appalachian Ohio, and southeastern West Virginia) have a large 

number of dark-colored counties, indicating that a high number of counties in this subregion have cancer 

mortality rates among the worst-performing quintile in the country (highest 20 percent). In contrast, many 

counties in northern Georgia have the lightest color, indicating a number of counties in the bestperforming national quintile (the lowest 20 percent of values nationally). 

Figure 6: Explanation of Thematic Maps

Dark colors

denote

“unhealthy”

values ‐‐‐ here,

high rates of

cancer mortality.

Light colors

denote “healthy”

values ‐‐‐ here,

low rates of

cancer mortality.

Orange lines

denote the

borders of the

Appalachian

region and  

subregions

Dark grey (not

shown on this

map) denote

suppressed

values ‐‐‐ those

values the data

provider deem

not precise

enough to report

Legend shows

the range of

values for each

quintile of

national counties

 

2 Technically, the number may vary by one between groups. For example, there are 3113 counties analyzed, which does not

divide equally into groups of five, meaning for indicators with complete data, three groups will have 623 and two will have 622.
CREATING A CULTURE OF 

HEALTH IN APPALACHIA Introduction | HEALTH DISPARITIES

31 

Box Plots 

A box plot is a type of graph that shows the distribution of data. Comparing box plots among different 

groups shows how the median of each group compares to the other groups, how much variation exists 

within each group, and how the variation compares between the groups. In this report, box plots for each 

measure compare the national average to the medians for: the Appalachian Region and the nonAppalachian U.S.; each Appalachian subregion; and distressed and non-distressed Appalachian counties. 

The diagram below illustrates the elements of “boxes” and “whiskers.” 

Figure 7: How to Read a Box Plot 

The edges of the whiskers and the black line represent specific statistics calculated from the data. For 

example, the black line denotes the median (half of values are greater than this value, half are less than 

this value). The lower and upper edges of the box represent the 25th and 75th percentiles, respectively. 

The 25th percentile is the value for which 25 percent of county values are less, and the remainder (75 

percent) are greater. The 75th percentile is defined similarly. The caps of the whiskers are defined as 

“adjacent values” (Tukey, 1977). The upper adjacent value (“top whisker”) is the largest observed value 

that is less than or equal to the 75th percentile plus 3/2 of the difference between the 75th and 25th 

percentile. The lower adjacent value is defined similarly. Outside values —the dots described as 

“unusually high or low values”—are those values that lie outside the adjacent values. 

The Cancer Mortality example in Figure 8 is annotated with three takeaways that one can learn from the 

box plot. The horizontal grey line is the national average and the horizontal black line in the middle of 

each box is the median for the group. The first two plots compare cancer mortality rates in both the 

Appalachian Region and the non-Appalachian U.S. to the national average. The first takeaway is that 

cancer mortality among counties in the Appalachian Region is generally higher than counties in the nonAppalachian U.S. (Point 1). This is seen by comparing the corresponding portion of the box plot between 

the two grey boxes. The box on the left represents counties in Appalachia; the box on the right denotes 

counties not in Appalachia. For each portion of the non-Appalachian box, the corresponding portion of 

the Appalachia box is “higher.” 
CREATING A CULTURE OF 

HEALTH IN APPALACHIA Introduction | HEALTH DISPARITIES

32 

The blue boxes denote the distribution of Appalachian counties by geographic subregion. Here, we see 

that most of the counties in the Central subregion (middle box) exceed the national average (Point 2). This 

is evident by reviewing the box—the entire box and most of the lower “whisker” lies above the line. This 

means that at least 75 percent (the lower edge of the box) of counties in the Central subregion exceed the 

national average, and most of the remainder do as well (only a little of the whisker extends below the 

national average). 

The orange boxes on the far right of the plot show the distribution of values for Appalachian counties that 

are economically distressed versus those that are not distressed. Here, we see that the 75 percent highest 

values of the economically distressed have values comparable to the highest 25 percent of the nondistressed (Point 3). That is, the lower edge of the box of Distressed is roughly equal to the value of the 

upper edge of Non-distressed. The difference between these two distributions is larger than the difference 

between the Appalachian and non-Appalachian values (grey boxes at far left, where the “upward shift” is 

small relative to the “upward shift” seen in the orange boxes.) 

Figure 8: Box Plot of Cancer Mortality Rates by Geography and Economic Status, 2008–2014

Data source: National Center for Health Statistics. Compressed Mortality File, 1999–2014 (machine-readable data file and 

documentation, CD ROM Series 20, No. 2T) as compiled from data provided by the 57 vital statistics jurisdictions through the Vital 

Statistics Cooperative Program. Hyattsville, Maryland. 2015. 

Point 1: Counties in

Appalachia tend to

have higher rates of

cancer mortality

than counties not

in Appalachia; for

each portion of the

non‐Appalachian

box, the

corresponding

portion of the

Appalachian box is

higher.

Point 2: most counties in the Central subregion of

Appalachia tend to have higher rates of cancer

mortality than the national average; the box and

most the lower whisker lies above the national

average line (shown in grey).  

The highest 75% of

values lie above the

LOWER edge of the

box.

The highest 25% of

values lie above the

HIGHER edge of the

box.  

Point 3: Most

Distressed counties in

Appalachia tend to

have higher rates of

cancer mortality than

only the highest values

of the non‐distressed;

the highest 75% of

distressed counties

values comparable to

the highest 25% of non‐

distressed