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Executive Summary 

About the Appalachian Region 

Measuring Health Disparities in the Appalachian Region 

Key Findings 

Trends 

Next Steps 
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Health Disparities in Appalachia 

Executive Summary 

HEALTH 

DISPARITIES

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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 disparities in health 

outcomes in the Appalachian Region compared to the United States as a whole, as well as disparities 

within the Appalachian Region; identify “Bright Spots,” or communities that exhibit better-than-expected 

health outcomes given their resources; and explore a sample of the Bright Spot communities through indepth, field-based case studies. Taken together, these reports will provide a basis for understanding and 

addressing health issues in the Appalachian Region. This research initiative aims to identify factors that 

support a Culture of Health in Appalachian communities and explore replicable activities, programs, or 

policies that encourage better-than-expected health outcomes that could translate into actions that other 

communities can replicate. 

This first report, Health Disparities in Appalachia, measures population health in Appalachia and 

documents disparities between the Region and the nation as a whole, as well as disparities within 

the Appalachian Region. 

ABOUT THE APPALACHIAN REGION 

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 (see Figure 1). The Region covers 205,000 square 

miles and 420 counties, and is home to more than 25 million people. Forty-two percent of the Region’s 

population is rural, compared with 20 percent of the nation’s. 

The Appalachian Region's economy, which was once highly dependent on extractive industries, has 

become more diversified in recent times and now includes larger shares of manufacturing and 

professional services, among other industries. Appalachia has made significant progress over the past five 

decades: its poverty rate, which was 31 percent in 1960, had fallen to 17.2 percent over the 2010–2014 

period. The number of high-poverty counties in the Region (those with poverty rates more than 1.5 times 

the U.S. average) declined from 295 in 1960 to 91 over the 2010–2014 period. 

Despite the progress made in the Region, many challenges remain, with Appalachian incomes, poverty 

rates, unemployment rates, and postsecondary education levels still lagging behind performance at the 

national level. In addition to these socioeconomic deficits, for many of the health drivers and outcomes 

discussed in this report, the Region performs poorly when compared to the nation as a whole. Progress in 

the socioeconomic and health spheres are often interrelated, if not interdependent, and much work 

remains. 
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Figure 1: Map of the Appalachian Region 

MEASURING HEALTH DISPARITIES IN THE APPALACHIAN REGION 

A range of indicators are used in this report to measure population health in Appalachia and document 

health disparities between the Region and the nation as a whole. This report includes 41 measures of 

population health, organized into 9 domains: Mortality, Morbidity, Behavioral Health, Child Health, 

Community Characteristics, Lifestyle, Health Care Systems, Quality of Care, and Social Determinants. 

The domains reflect: 

 Current health status: Mortality, Morbidity, and Behavioral Health; 

 Generational health and health care: Child Health, Health Care Systems, and Quality of Care; 

and 

 Risk factors and determinants of health: Lifestyle, Community Characteristics, and Social 

Determinants. 

The indicators provide an overview of population health and include both health outcomes—such as 

specific measures of mortality and morbidity—and factors that drive or influence health outcomes—such 

as smoking prevalence, physical inactivity, and the supply of healthcare providers. 

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 quintile would contain 84 counties (20 percent of the 
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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. 

KEY FINDINGS 

Of the 41 indicators examined in this report, the Region performs better than the nation overall on 8: HIV 

prevalence, travel time to work, excessive drinking, student-teacher ratio, chlamydia prevalence, 

percentage of the population under age 65 that is uninsured, diabetes monitoring among Medicare 

patients, and the social association rate. 

For the remaining 33 indicators in this report, the performance in the Appalachian Region is worse than 

the performance in the United States as a whole. This report includes 7 of the 10 leading causes of death 

in the United States: heart disease, cancer, chronic obstructive pulmonary disease (COPD), injury, stroke, 

diabetes, and suicide—and the Appalachian Region has higher mortality rates than the nation for each. 

Mortality due to poisoning—which includes drug overdoses—is markedly higher in the Region than the 

nation as a whole. 

The Appalachian Region’s number of physically unhealthy days, mentally unhealthy days, and prevalence 

of depression are all higher than the national averages for these measures. Obesity, smoking, and physical 

inactivity—risk factors for a number of health outcomes—are all higher in Appalachia than in the nation 

overall. The Region also has lower supplies of healthcare professionals when compared to the United 

States as a whole, including primary care physicians, mental health providers, specialty physicians, and 

dentists. Lower household incomes and higher poverty rates—both social determinants of health—reflect 

worse living conditions in the Region than in the nation as a whole. 

This report also examines the changes over the last 20 years in eight measures: heart disease mortality, 

cancer mortality, stroke mortality, infant mortality, the supply of primary care physicians, poverty rates, 

education levels, and years of potential life lost. Over the past two decades, the Appalachian Region has 

experienced improvements in seven of the eight measures. However, the progress made by the Region 

often comes up short when compared to the progress made by the United States overall, and indicates a 

widening gap in overall health between Appalachia and the nation as a whole. 

Mortality 

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

a broad measure of premature mortality. There are seven measures of mortality included in this domain: 

 Heart disease 

 Cancer 

 COPD 

 Injury 

 Stroke 

 Diabetes 

 Years of Potential Life Lost (YPLL)

Each measure of mortality in this domain is higher (worse) in the Appalachian Region than in the 

nation as a whole. 
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Every mortality indicator is higher in the Region than in the nation overall: heart disease is 17 percent 

higher; cancer is 10 percent higher; COPD is 27 percent higher; injury is 33 percent higher; stroke is 14 

percent higher; and diabetes is 11 percent higher. 

Considering death broadly, YPLL, a measure of premature mortality, is 25 percent higher in the Region 

than in the nation as a whole. 

The Appalachian Region’s rural counties have higher mortality rates than the Region’s large metro 

counties for each of the indicators, signifying a stark rural-urban divide in the Region: heart disease is 27 

percent higher; cancer is 15 percent higher; COPD is 55 percent higher; injury is 47 percent higher; stroke 

is 8 percent higher; and diabetes is 36 percent higher. 

YPLL is 40 percent higher in rural Appalachian counties than in the Region’s large metro counties. 

The distributions of the Mortality indicators among national quintiles for Appalachian counties are shown 

in Table 1. Of the 420 counties in the Appalachian Region, 163 counties (39 percent) have COPD 

mortality rates in the worst-performing national quintile, while only 27 counties in the Region (6 percent) 

are in the best-performing national quintile. There are 158 counties (38 percent) in the worst-performing 

national quintiles for both heart disease and cancer mortality. Only 13 counties (3 percent) are in the bestperforming quintile for YPLL. These distributions show that mortality rates are disproportionately higher 

throughout the Appalachian Region when compared to the nation as a whole. 

Table 1: Distributions of Mortality Rates among National Quintiles for Appalachian Counties 

Indicator 

Best 

Quintile 

2nd Best 

Quintile 

Middle 

Quintile 

2nd Worst 

Quintile 

Worst 

Quintile 

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

Heart disease deaths 15 4% 56 13% 76 18% 115 27% 158 38% 

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

COPD deaths 27 6% 54 13% 83 20% 93 22% 163 39% 

Injury deaths 28 7% 59 14% 80 19% 106 25% 147 35% 

Stroke deaths 40 10% 69 16% 90 21% 111 26% 110 26% 

Diabetes deaths 60 14% 70 17% 91 22% 100 24% 99 24% 

YPLL 13 3% 63 15% 81 19% 105 25% 156 37% 

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. 

Morbidity 

The indicators in the Morbidity domain explore the prevalence of disease and other health conditions. 

There are five indicators of morbidity in this report: 

 Physically unhealthy days 

 Mentally unhealthy days 

 HIV prevalence 

 Diabetes prevalence 

 Obesity prevalence 
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With the exception of HIV rates, the outcomes in Appalachia for each of these measures is higher 

(worse) than in the nation as a whole. 

Appalachian residents report 14 percent more physically unhealthy days and mentally unhealthy days 

than the nation as a whole. The diabetes prevalence rate in the Region (11.9 percent) is slightly higher 

than the nation overall (9.8 percent). Likewise, the prevalence of adult obesity is higher in Appalachia 

(31.0 percent) than in the United States as a whole (27.4 percent). 

Residents of rural Appalachian counties have higher numbers of physically unhealthy days, higher 

numbers of mentally unhealthy days, higher diabetes prevalence, and a higher prevalence of obesity than 

residents of the Region’s large metro counties. Residents living in rural counties in the Region report 24 

percent more physically unhealthy days than those living in large metro counties and 10 percent more 

mentally unhealthy days. Residents of rural Appalachian counties are also more likely to be obese than 

those living in large metro counties (33.1 percent compared to 29.5 percent). 

The distributions of the Morbidity indicators among national quintiles for Appalachian counties are 

shown in Table 2. Considering mentally unhealthy days, 210 counties (50 percent) are in the worstperforming national quintile for this measure, while only 2 counties in the Region (less than 1 percent) are 

in the best-performing national quintile. Of the 420 counties in the Region, 180 are in the worstperforming national quintile for diabetes prevalence (43 percent), while only 12 counties (3 percent) are 

in the top-performing quintile. These results show that many health conditions are disproportionately 

worse throughout much of Appalachia when compared to the nation as a whole. 

Table 2: Distributions of Morbidity Indicators among National Quintiles for Appalachian Counties 

Indicator 

Best 

Quintile 

2nd Best 

Quintile 

Middle 

Quintile 

2nd Worst 

Quintile 

Worst 

Quintile 

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

Physically unhealthy days 5 1% 39 9% 93 22% 106 25% 177 42% 

Mentally unhealthy days 2 0% 19 5% 96 23% 93 22% 210 50% 

HIV prevalence 89 21% 109 26% 104 25% 61 15% 20 5% 

Diabetes prevalence 12 3% 32 8% 68 16% 128 30% 180 43% 

Obesity prevalence 45 11% 69 16% 74 18% 106 25% 126 30% 

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. 

Behavioral Health 

The measures in the Behavioral Health domain examine issues related to both mental health and 

substance abuse. There are five measures in this domain: 

 Depression prevalence among Medicare beneficiaries 

 Suicide 

 Excessive drinking 

 Poisoning mortality 

 Opioid prescriptions among Medicare beneficiaries 
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While excessive drinking in the Appalachian Region is lower (better) than in the nation as a whole, 

the Region performs worse than the nation on each of the other measures in this domain. 

The poisoning mortality rate in Appalachia—which includes drug overdoses—is 37 percent higher than 

the national rate, and the suicide rate in the Region is 17 percent higher than the national rate. The 

prevalence of depression among Medicare beneficiaries is higher in the Region (16.7 percent) than in the 

nation as a whole (15.4 percent). 

Residents of the Appalachian Region’s rural counties are 21 percent more likely to commit suicide than 

those living in the Region’s large metro counties, and the poisoning mortality rate is 40 percent higher in 

the Region’s rural counties than in its large metro counties. Depression prevalence among Medicare 

beneficiaries is also slightly higher in the Region’s rural counties (16.9 percent) than in its large metro 

counties (15.6 percent). 

The distributions of the Behavioral Health indicators among national quintiles for Appalachian counties 

are shown in Table 3. For poisoning mortality, 195 of the 420 counties in the Appalachian Region (46 

percent) are in the worst-performing national quintile, while only 24 counties (6 percent) are in the bestperforming national quintile. For depression prevalence among Medicare beneficiaries, 161 counties (38 

percent) are in the worst-performing national quintile, and only 22 counties (5 percent) are in the bestperforming national quintile. 

Table 3: Distributions of Behavioral Health Indicators among National Quintiles for Appalachian 

Counties 

Indicator 

Best 

Quintile 

2nd Best 

Quintile 

Middle 

Quintile 

2nd Worst 

Quintile 

Worst 

Quintile 

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

Depression prevalence 22 5% 54 13% 69 16% 114 27% 161 38% 

Suicide incidence 46 11% 69 16% 108 26% 127 30% 70 17% 

Excessive drinking 202 48% 92 22% 82 20% 41 10% 3 1% 

Poisoning mortality 24 6% 31 7% 56 13% 114 27% 195 46% 

Opioid prescriptions 51 12% 77 18% 91 22% 100 24% 101 24% 

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. 

Child Health 

Circumstances surrounding birth are explored in the Child Health domain. There are three measures in 

this domain: 

 Infant mortality 

 Low birth weight 

 Teen births 

The Region performs worse than the nation on each of these measures. 

The infant mortality rate is 16 percent higher in the Appalachian Region than in the nation as a whole, and 

the percentage of low birth weight babies is higher in the Region (8.7 percent) than in the nation (8.1 

percent). 
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The infant mortality rate in the Appalachian Region’s rural counties is 19 percent higher than the rate in 

the Region’s large metro counties and the teen birth rate in the Region’s rural counties is 72 percent 

higher than the rate in Appalachia’s large metro counties. 

The distributions of the Child Health indicators among national quintiles for Appalachian counties are 

shown in Table 4. Of the 420 counties in the Appalachian Region, 127 (30 percent) are in the worstperforming national quintile for the incidence of low birth weight babies, while only 12 counties (3 

percent) are in the best-performing quintile. The distribution of the infant mortality rate shows that only 

24 Appalachian counties (6 percent) rank in the top-performing national quintile. 

Table 4: Distributions of Child Health Indicators among National Quintiles for Appalachian 

Counties 

Indicator 

Best 

Quintile 

2nd Best 

Quintile 

Middle 

Quintile 

2nd Worst 

Quintile 

Worst 

Quintile 

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

Infant mortality 24 6% 73 17% 112 27% 124 30% 87 21% 

Low birth weight 12 3% 58 14% 90 21% 132 31% 127 30% 

Teen births 44 10% 66 16% 95 23% 131 31% 83 20% 

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. 

Community Characteristics 

The measures included in the Community Characteristics domain examine aspects of the external 

environment largely outside of residents’ control. Three measures are included in this domain: 

 Travel time to work 

 Grocery store availability 

 Student-teacher ratio 

Appalachia performs better than the nation as a whole on two of these measures: travel time to 

work and the student-teacher ratio. 

The average travel time to work in the Region is 25 minutes, which is just slightly lower than the national 

average of 26 minutes. The student-teacher ratio in Appalachia is 14.3, which is a lower (better) ratio than 

the national average of 16.5. With grocery store availability, however, the Region performs worse than 

the United States as a whole, with 14 percent fewer grocery stores per 1,000 population. 

Unlike many other indicators in this report, rural areas throughout Appalachia perform better than large 

metro areas in the Region for each of the three variables in this domain. 

The distributions of the Community Characteristics indicators among national quintiles for Appalachian 

counties are shown in Table 5. Despite the Region’s slightly lower average travel time to work, 142 

counties (34 percent) still rank in the worst-performing national quintile, and only 5 counties (1 percent) 

rank in the best-performing quintile. 
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Table 5: Distributions of Community Characteristics Indicators among National Quintiles for 

Appalachian Counties 

Indicator 

Best 

Quintile 

2nd Best 

Quintile 

Middle 

Quintile 

2nd Worst 

Quintile 

Worst 

Quintile 

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

Travel time to work 5 1% 62 15% 101 24% 110 26% 142 34% 

Grocery store availability 39 9% 99 24% 116 28% 96 23% 70 17% 

Student-teacher ratio 37 9% 85 20% 116 28% 115 27% 52 12% 

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. 

Lifestyle 

Individual choices and habits that play an important role in the health of a population are explored in the 

Lifestyle domain. There are three measures in this domain: 

 Physical inactivity 

 Smoking prevalence 

 Chlamydia prevalence 

Appalachia performs worse than the nation as a whole on two of these indicators: physical 

inactivity and smoking. 

In the Appalachian Region, 28.4 percent of people report being physically inactive, a figure higher than 

the 23.1 percent reported for the United States as a whole. Nearly 20 percent of all adults in the 

Appalachian Region report being cigarette smokers, a figure higher than the 16.3 percent found at the 

national level. 

In the Appalachian Region’s rural counties, 31.8 percent of residents report being physically inactive, a 

figure much higher than the 25.2 percent in the Region’s large metro areas. Residents in the Region’s 

rural counties also report a higher smoking prevalence, with 22.5 percent of adults being cigarette 

smokers, compared to just 17.3 percent of those living in the Region’s large metro areas. 

The distributions of the Lifestyle indicators among national quintiles for Appalachian counties are shown 

in Table 6. Of the 420 counties in the Region, 179 (43 percent) rank in the worst-performing national 

quintile for physical inactivity. There are 189 counties in the Region (45 percent) that rank in the worstperforming national quintile for cigarette smoking, while only 17 counties (4 percent) rank in the bestperforming national quintile. 
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Table 6: Distributions of Lifestyle Indicators among National Quintiles for Appalachian Counties 

Indicator 

Best 

Quintile 

2nd Best 

Quintile 

Middle 

Quintile 

2nd Worst 

Quintile 

Worst 

Quintile 

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

Physical inactivity 18 4% 60 14% 79 19% 84 20% 179 43% 

Smoking prevalence 17 4% 27 6% 67 16% 120 29% 189 45% 

Chlamydia incidence 132 31% 111 26% 84 20% 50 12% 36 9% 

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. 

Health Care Systems 

The Health Care Systems domain includes measures related to the availability of, and access to, 

healthcare. There are seven measures in this domain: 

 Primary care physicians 

 Mental health professionals 

 Specialty physicians 

 Dentists 

 Percentage of the population under age 65 that is uninsured 

 Heart disease hospitalizations among Medicare beneficiaries 

 COPD hospitalizations among Medicare beneficiaries 

The Appalachian Region performs worse than the United States as a whole on six of the seven 

measures. Only the percentage of the population under age 65 that is uninsured is slightly lower 

(better) in the Region than in the nation as a whole, although the data here largely predate the 

implementation of the Affordable Care Act. 

The supply of primary care physicians is 12 percent lower in the Appalachian Region than in the nation as 

a whole. The deficit between Appalachia and the United States overall is even larger for the supply of 

mental health providers (35 percent lower), specialty physicians (28 percent lower), and dentists (26 

percent lower). Hospitalization rates among Medicare beneficiaries are much higher in the Region for 

both COPD (23 percent higher in the Appalachia than in the United States) and heart disease (17 percent 

higher). 

The supply of primary care physicians in rural counties in Appalachia is 20 percent lower than the supply 

in the Region’s large metro counties. The supply of both specialists (57 percent lower) and dentists (36 

percent lower) are also lower in the Region’s rural counties when compared to large metro counties. 

COPD hospitalization rates (39 percent higher) and heart disease hospitalization rates (13 percent) are 

also higher in Appalachia’s rural counties. The uninsured rate for the population under age 65 is 18.2 

percent in rural Appalachian counties compared to 14.7 percent in the Region’s large metro counties. 

The distributions of the Health Care Systems indicators among national quintiles for Appalachian 

counties are shown in Table 7. Of the 420 counties in the Region, 203 counties (48 percent) rank in the 

worst national quintile for COPD hospitalizations, while only 12 counties (3 percent) are in the bestperforming national quintile. Likewise, 179 counties (43 percent) rank in the worst national quintile for 

heart disease hospitalizations while only 7 counties (2 percent) rank in the best-performing national 

quintile. 
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Table 7: Distributions of Health Care Systems Indicators among National Quintiles for 

Appalachian Counties 

Indicator 

Best 

Quintile 

2nd Best 

Quintile 

Middle 

Quintile 

2nd Worst 

Quintile 

Worst 

Quintile 

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

Primary care physicians 56 13% 84 20% 106 25% 95 23% 79 19% 

Mental health providers 42 10% 81 19% 105 25% 116 28% 76 18% 

Specialist physicians 67 16% 103 25% 94 22% 100 24% 56 13% 

Dentists 35 8% 80 19% 99 24% 115 27% 91 22% 

Uninsured population 53 13% 91 22% 117 28% 111 26% 48 11% 

Heart disease hospitalizations 7 2% 43 10% 74 18% 117 28% 179 43% 

COPD hospitalizations 12 3% 29 7% 75 18% 101 24% 203 48% 

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. 

Quality of Care 

The types of care that are available to residents in a community are examined in the Quality of Care 

domain. There are three measures in this domain: 

 Percentage of medical doctors that use electronic prescribing technology 

 Percentage of Medicare beneficiaries ages 67 to 69 who have recently received a mammogram 

 Diabetes monitoring among Medicare beneficiaries 

For each of these three measures, the values reported in Appalachia are similar to those reported in 

the United States as a whole. 

Medical doctors are somewhat less likely to use electronic prescribing in the Appalachian Region (63.8 

percent of doctors) compared to the nation overall (65.8 percent). Mammogram screening percentages are 

comparable for the Region (61.4 percent) and the United States as a whole (62.1 percent), as are diabetes 

monitoring percentages, with Appalachia (85.9 percent) and the nation overall (84.7 percent) reporting 

similar figures. 

Medical doctors in rural areas throughout the Region are less likely to use electronic prescribing (60.6 

percent of doctors) than those in large metro areas (64.7 percent). Medicare-covered women ages 67 to 69 

are less likely to have had a recent mammogram in rural areas (57.3 percent) than those in large metro 

areas (58.9 percent). 

The distributions of the Quality of Care indicators among national quintiles for Appalachian counties are 

shown in Table 8. The indicators in this domain are relatively evenly distributed compared to many other 

indicators in this report. 
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Table 8: Distributions of Quality of Care Indicators among National Quintiles for Appalachian 

Counties 

Indicator 

Best 

Quintile 

2nd Best 

Quintile 

Middle 

Quintile 

2nd Worst 

Quintile 

Worst 

Quintile 

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

Electronic prescriptions 58 14% 74 18% 94 22% 107 25% 82 20% 

Mammogram screenings 56 13% 69 16% 91 22% 99 24% 104 25% 

Diabetes monitoring 74 18% 103 25% 120 29% 85 20% 38 9% 

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. 

Social Determinants 

The measures in the Social Determinants domain examine the conditions in which people live and work. 

There are five measures in this domain: 

 Median household income 

 Household poverty rate 

 Percentage of the population receiving disability benefits 

 Percentage of the population with some level of college education 

 Social association rate 

The Appalachian Region performs worse than the United States as a whole on four of the five 

measures—the social association rate is the only indicator with better performance in the Region. 

Median household income in the Appalachian Region is 19 percent lower than the national median, and 

adults ages 25 to 44 are less likely to have some type of post-secondary education in the Region (57.1 

percent) than in the United States overall (63.3 percent). The household poverty rate in Appalachia is 

higher than the national rate (17.2 percent compared to 15.6 percent), and more people receive disability 

benefits in the Region (7.3 percent) than in the nation as a whole (5.1 percent). 

Rural counties throughout Appalachia perform markedly worse on the four measures in which the Region 

as a whole already lags behind national performance. Median household income in rural Appalachia is 34 

percent lower than the median income in large metro counties throughout the Region. Education levels 

(49.0 percent in rural Appalachian counties; 65.1 percent in large metro counties), household poverty 

rates (23.0 percent in Appalachia’s rural counties; 13.6 percent in the Region’s large metro counties), and 

the receipt of disability benefits (11.2 percent in rural Appalachian counties; 5.5 percent in Appalachia’s 

large metro counties) all show a stark rural-urban divide. 

The distributions of the Social Determinants indicators among national quintiles for Appalachian counties 

are shown in Table 9. There are 203 Appalachian counties (48 percent) that rank in the worst-performing 

national quintile on receipt of disability benefits, while only 9 counties (2 percent) rank in the bestperforming quintile. For median household income, 159 counties (38 percent) rank in the worstperforming national quintile, while only 19 counties (5 percent) rank in the best-performing quintile. 

These results show that outcomes for many social determinants are disproportionately worse throughout 

much of the Appalachian Region when compared to the nation as a whole. 
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Table 9: Distributions of Social Determinants Indicators among National Quintiles for Appalachian 

Counties 

Indicator 

Best 

Quintile 

2nd Best 

Quintile 

Middle 

Quintile 

2nd Worst 

Quintile 

Worst 

Quintile 

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

Median household income 19 5% 33 8% 91 22% 118 28% 159 38% 

Household poverty 17 4% 52 12% 95 23% 134 32% 122 29% 

Disability 9 2% 19 5% 59 14% 130 31% 203 48% 

Education: some college 20 5% 39 9% 83 20% 128 30% 150 36% 

Social associations 45 11% 89 21% 102 24% 98 23% 86 20% 

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. 

TRENDS 

The trends section examines the changes in eight indicators over a period of approximately two decades. 

The changes in the Appalachian Region are compared to the United States as a whole for these measures 

examining premature death, causes of death, child and maternal health, healthcare access, and 

socioeconomic status. 

For seven of the eight indicators considered in this section, the Appalachian Region—along with the 

nation as a whole—experienced improvements over the past two decades. However, the 

improvements made by the nation overall generally outpaced those made by the Region, indicating 

increasing disparities between Appalachia and the United States as a whole. 

Table 10 shows the percentage changes over the past two decades in Appalachia and the United States for 

six of the eight variables included in this section. The Appalachian Region experienced a decrease 

(improvement) in all measures of mortality, but lagged the improvement experienced by the nation as a 

whole. Appalachia outperformed the rate of change for the nation overall in just one measure: the supply 

of primary care physicians. 

Table 10: Percentage change in selected measures, the United States and Appalachia 

Indicator United States Appalachia 

Change between 1989–1995 and 2008–2014: 

 YPLL -24% -8% 

 Stroke mortality -40% -35% 

 Cancer mortality -21% -14% 

 Heart disease mortality -43% -39% 

 Infant mortality -28% -19% 

Change between 1990 and 2013: 

 Primary care physicians 27% 31% 

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. 
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Two indicators are not included in the table above: household poverty rates and the percentage of the 

population with a high school degree. Both Appalachia and the nation as a whole experienced an increase 

(worsening) in the household poverty rate between 1995 and 2014, with the Region’s rate increasing from 

14.2 percent to 17.2 percent, while the national rate increased at a slightly slower pace, going from 13.6 

percent to 15.6 percent. Between 1990 and 2009–2013, Appalachia made great strides in the percentage 

of its population with a high school degree, improving from 68.4 percent to 84.6 percent. The nation as a 

whole also saw an increase in this measure, going from 75.7 percent in 1990 to 85.9 percent in 2009–

2013. 

NEXT STEPS 

This report—measuring population health and documenting health disparities in the Appalachian 

Region—is the first in a series exploring health issues in Appalachia. 

The information documented in this report provides context for the subsequent reports in this series that 

will explore Bright Spots, or Appalachian communities with better-than-expected health outcomes given 

their resources. Resources here are interpreted broadly, and include the health system, the environment, 

and socioeconomic factors, among others. Much of the data presented in this report will be used to 

establish a statistical framework for identifying Bright Spots, including factors that reflect a Culture of 

Health. Once Appalachian counties performing better than expected have been statistically identified, a 

sample of these communities will be explored through in-depth, field-based case studies. Working with 

these communities, the case studies will identify replicable activities, programs, or policies that encourage 

better-than-expected health outcomes that could translate into actions that other communities can 

replicate. 
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