Underlying Socioeconomic

Factors Influencing Health

Disparities in the Appalachian

Region.

Final Report

March 2008

Contract No. CO-15198

Mary Babb Randolph Cancer Center/

Office for Social Environment and Health Research

Department of Community Medicine

Robert C. Byrd Health Sciences Center, West Virginia University
Prepared for the Appalachian Regional Commission by: 

Joel A. Halverson, PhD 

Director, Office for Social Environment and Health Research 

Department of Community Medicine 

Mary Babb Randolph Cancer Center 

West Virginia University 

and 

Greg Bischak, Ph.D. 

Senior Economist 

Appalachian Regional Commission 

Underlying Socioeconomic Factors Influencing Health Disparities in the Appalachian Region 
Underlying Socioeconomic Factors Influencing Health Disparities in the Appalachian Region page i

Table of Contents 

Executive Summary .......................................................... iii 

Introduction ......................................................... 1 

Section I. Data and Methods ......................................................... 4 

Section II. Disparities in Premature Mortality in the Appalachian Region ........ 11 

II A. All Cause Mortality ................................................. 11 

II.B. Heart Disease Mortality ................................................. 13 

II C. Cancer Mortality ................................................. 15 

II.D. Stroke Mortality ................................................. 17 

 

Section III. Associations between Socioeconomic Conditions and Disparities in 

Premature Mortality ................................................. 19 

 III.A. National Associations ................................................. 19

III.A.1 All Cause Mortality ................................................. 19 

III.A.2 Heart Disease Mortality ................................................. 26 

III.A.3 Cancer Mortality ................................................. 32 

III.A.4 Stroke Mortality ................................................. 38 

 III.B. Appalachian Associations ..................................................44

III.B.1 All Cause Mortality ................................................. 44 

III.B.2 Heart Disease Mortality ................................................. 50 

III.B.3 Cancer Mortality ................................................. 56 

III.B.4 Stroke Mortality ................................................. 62 
Underlying Socioeconomic Factors Influencing Health Disparities in the Appalachian Region page ii

Section IV. Conclusions ................................................69

References ................................................73 

APPENDIX I. Distribution of socioeconomic factors among Appalachian counties and 

surrounding areas. ................................................77 

APPENDIX II. Premature death rates for Appalachian counties...........................85

APPENDIX III. National and Regional tables indicating the associations between 

premature mortality and socioeconomic factors for Appalachian counties. .........95
Underlying Socioeconomic Factors Influencing Health Disparities in the Appalachian Region page iii

Executive Summary 

 This study investigates associations between measures of socioeconomic 

condition and rates of premature mortality for leading causes of death for counties in the 

U.S., with a focus on the Appalachian region. The overall goal is to elucidate 

relationships between observed health outcomes in the region and underlying 

socioeconomic conditions that may be contributing factors in shaping these outcomes. 

The motivation for this investigation arose from findings in an earlier study conducted for 

the Appalachian Regional Commission entitled An Analysis of Disparities in Health 

Status and Access to Medical Care in the Appalachian Region (Halverson et al, 2004) 

which found that the “Appalachia continues to suffer adverse socio-economic conditions 

(higher unemployment, lower educational achievement, lower per capita income), and 

there does appear to be some association between areas with more adverse 

socioeconomic conditions and adverse health outcomes.” Yet, the report noted that 

“...the direct role of socioeconomic conditions in influencing health disparities is not 

clear.” The importance of further research on this topic is underscored by the central 

finding of the study which found that the Appalachian region experiences considerable 

excesses in mortality from major causes of death and illness when compared to the rest of 

the nation. In addition, the study demonstrated significant within-region variability in 

mortality, hospitalization, behavioral risks, and socioeconomic conditions. 

 A key finding from the 2004 study was a disturbing pattern of extremely high 

rates of premature mortality from major causes of death which was evident for specific 

areas in the Appalachian region. In several cases specific areas in the Appalachian region 

demonstrated the largest clusters of the highest death rates in the U.S. High death rate 

clusters occurred consistently in the Central Appalachian region for heart disease, all-site 

cancers, lung cancer, and chronic obstructive pulmonary disease. For a number of 

specific causes of death, clear geographic gradients exist where the central and southern 

portion of the region exhibit more adverse outcomes relative to the northern portion of 

the region. 

 Observed outcome patterns among U.S. counties provide strong evidence of areabased (or place-based) disparities in health. In addition, strong spatial patterns in health 

outcomes suggest associations with underlying socioeconomic factors that may 

ultimately contribute to observed variations in health outcome patterns. It is important to 

understand local factors that contribute to observed outcomes in order to determine which 

social, political, economic, public health, and medical care structures need to be engaged 

to improve health outcomes at the local level and ultimately eliminate health disparities. 

 This study first updates aspects of the 2004 study by examining geographic 

disparities in premature mortality for all-causes of death and three major causes of death 

among counties in the U.S., with particular emphasis on the Appalachian region. Next the 

study computes associations with underlying socioeconomic factors that may contribute 

to observed outcome patterns among local populations. The goal of this study is to 

examine area-based measures of socioeconomic condition as opposed to individual 

socioeconomic status (SES). There are two basic reasons for this approach. First, most 
Underlying Socioeconomic Factors Influencing Health Disparities in the Appalachian Region page iv

individual-based public health data includes limited information about individual 

socioeconomic status (largely because of confidentiality restrictions) and therefore 

individual analyses cannot be performed. Second, because the focus is on place-based 

disparities, area-level measures of socioeconomic condition are the appropriate approach 

to examine these associations. 

 Five indicators of socioeconomic condition were selected for this analysis: 

Percent Urban Population, Median Family Income, Unemployment Rate, Percent of 

Persons Living in Poverty, and the Percent of Persons without Health Insurance. The 

specific statistical technique used to derive estimates of association is called Local 

Indicators of Spatial Association (LISA). Separate analyses were conducted for the U.S. 

as a whole and for the Appalachian Region as a whole because the results of the LISA 

technique are highly dependent on the global mean to generate estimates. 

 There are two major findings from the results of this study. First, there are clear 

geographic disparities in premature mortality from leading causes of death at both the 

national and regional level which update and confirm the earlier analyses of health 

disparities for all-cause, heart disease, all-site cancer, and stroke mortality measures. 

Second, the results from the local indicators of spatial association exhibit two distinct 

types of statistically significant association between measures of socioeconomic 

conditions and health outcomes among neighboring counties: adverse outcomes as 

measured by associations of neighboring counties with relatively high mortality rates and 

poor socioeconomic conditions, and; favorable outcomes for associations of neighboring 

counties with low mortality rates and good socioeconomic conditions. 

 Two slightly different portraits of Appalachia emerge from the national and 

regional levels of analysis. At the national level the clearest spatial patterns of association 

are found when using the poverty rate and the percentage of persons without health 

insurance as the socioeconomic measures, with adverse health outcomes for heart disease 

and all-site cancer deaths spatially concentrated in the lower Mississippi Delta, parts the 

Southeastern U.S. and parts of Central and Southwestern portions of the Appalachian 

Region, as well as a few variable small clusters in the West. At the regional level well 

defined clusters with higher rates of mortality for heart disease and all-site cancer are 

found in parts of Central and Southwestern Appalachian compared to other parts of the 

region that are comparably disadvantaged on several socioeconomic measures. 

 Of five measures of socioeconomic condition evaluated in this study, poverty and 

the percentage of persons without health insurance consistently define localized areas that 

suffer the highest rates of premature mortality. There are a number of related factors, in 

addition to these direct measures of socioeconomic condition that may contribute to 

observed variations in the rates of premature mortality. Local differences in availability 

to local medical care resources, local health behaviors, industrial and occupational 

structure represent additional avenues for further research. Finally, the areas identified in 

this report with adverse health outcomes and poor socioeconomic conditions represent 

clear candidates for community level research to address these issues.