Photo: Brian Stansberry

Prepared by:

PDA, INC.

Raleigh, N.C.

THE CECIL G. SHEPS CENTER FOR HEALTH SERVICES RESEARCH

The University of North Carolina at Chapel Hill, Chapel Hill, N.C.

APPALACHIAN REGIONAL COMMISSION

Washington, D.C.

Disparities and Bright Spots

 HEALTH DISPARITIES

 IN APPALACHIA

The first report in a series exploring health 

issues in Appalachia

August 2017

CREATING A CULTURE OF 

HEALTH IN APPALACHIA Acknowledgments | HEALTH DISPARITIES

i 

ACKNOWLEDGMENTS

Robert Wood Johnson Foundation

The Robert Wood Johnson Foundation (RWJF) is the nation’s largest philanthropy dedicated to health. 

For more than 40 years, RWJF has supported research and programs targeting some of the nation’s most 

pressing health issues. 

RWJF provided funding for this research project as part of its Culture of Health Initiative. David M. Krol, 

MD, MPH, FAAP, Senior Program Officer, provided the impetus for the Creating a Culture of Health in 

Appalachia: Disparities and Bright Spots project and solicited the Appalachian Regional Commission 

and the Foundation for a Healthy Kentucky as partners.

Appalachian Regional Commission

The Appalachian Regional Commission (ARC) provided funding, leadership, and project management for 

the project. Established in 1965, ARC is a regional economic development agency that represents a 

partnership of federal, state, and local government. ARC’s mission is to innovate, partner, and invest to 

build community capacity and strengthen economic growth in Appalachia to help the Region achieve 

socioeconomic parity with the nation. 

Foundation for a Healthy Kentucky

The non-profit Foundation for a Healthy Kentucky was the grantee and fiscal agent for the project. Since 

2001, the Foundation for a Healthy Kentucky has been working to improve the health of Kentuckians 

through policy changes and community investments. Its mission is to address the unmet health care needs 

of Kentucky residents by developing and influencing health policy, improving access to care, reducing 

health risks and disparities, and promoting health equality. 

Principal Investigators

To implement the research, the Appalachian Regional Commission and the Foundation for a Healthy 

Kentucky named two Principal Investigators for the study: Julie L. Marshall, PhD, Economist, Division 

of Planning and Research for the Appalachian Regional Commission, and Gabriela Alcalde, DrPH, Vice 

President, Policy and Program for the Foundation for a Healthy Kentucky.
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ii

Authors 

PDA, Inc., in Raleigh, North Carolina, prepared this report in collaboration with the Cecil G. Sheps 

Center for Health Services Research at the University of North Carolina at Chapel Hill and the 

Appalachian Regional Commission. The principal authors of the report include: 

Julie L. Marshall, PhD, Division of Planning 

and Research, Appalachian Regional 

Commission 

Logan Thomas, MA, Division of Planning and 

Research, Appalachian Regional 

Commission 

Nancy M. Lane, MA, President, PDA, Inc.

G. Mark Holmes, PhD, Center Director, UNC

Cecil G. Sheps Center for Health 

Research

Thomas A. Arcury, PhD, Program Director, 

Wake Forest Baptist Medical Center 

Clinical and Translational Science 

Institute

Randy Randolph, MRP, Applications Analyst 

Programmer, UNC Cecil G. Sheps 

Center for Health Research

Pam Silberman, JD, DrPH, Associate Director 

for Policy Analysis, UNC Cecil G. 

Sheps Center for Health Research

William Holding, MHA, Senior Consultant 

and Data Analyst, PDA, Inc. 

Lisa Villamil, MAE, Assistant Professor, 

UNC Chapel Hill School of Media 

and Journalism

Sharita Thomas, MPP, Research Associate 

Cecil G. Sheps Center at the 

University of North Carolina at 

Chapel Hill 

Maura Lane, BA, communications and 

marketing executive

Janine Latus, MA, writer and speaker

Jonathan Rodgers, MHA, Consultant and 

Research Associate, PDA, Inc.

Kelly Ivey, BS, Project Manager, PDA, Inc.

Advisors and Contributors

The authors wish to thank Principal Investigator Julie Marshall for her comprehensive guidance 

throughout this project. 

The project benefited from insight from an Advisory Committee assembled by ARC, RWJF, and the 

Foundation for a Healthy Kentucky: 

Rui Li, PhD, Senior Economist, Division of 

Reproductive Health, Centers for 

Disease Control and Prevention

Rozelia Harris, MBA, Director of 

Mississippi Office of Rural Health 

and Primary Care, Mississippi State 

Department of Health 

Amy Martin, DrPh, MSPH, College of 

Dental Medicine, Medical 

University of South Carolina 

Wayne Myers, MD

Kadie Peters, Vice President of Community 

Impact for Health, United Way of 

Central Alabama

Others who assisted with review and feedback include: Eric Stockton, ARC Health Program Manager; 

Keith Witt, ARC Geographic Information Systems Analyst; Kostas Skordas, ARC Director, Planning and 

Research; Karen Entress, ARC Communications staff; and Diane Smith, ARC Communications staff. 
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iii

TABLE OF CONTENTS

Glossary of Terms ..................................................................................................................vii

List of Figures and Tables.......................................................................................................ix

Executive Summary..................................................................................................................1

 About the Appalachian Region.................................................................................................................3

Measuring Health Disparities in the Appalachian Region........................................................................4

Key Findings.............................................................................................................................................5

 Mortality ..............................................................................................................................................5

 Morbidity .............................................................................................................................................6

 Behavioral Health ................................................................................................................................7

 Child Health.........................................................................................................................................8

 Community Characteristics..................................................................................................................9

 Lifestyle .............................................................................................................................................10

 Health Care Systems..........................................................................................................................11

 Quality of Care...................................................................................................................................12

 Social Determinants...........................................................................................................................13

Trends .....................................................................................................................................................14

 Next Steps...............................................................................................................................................15

Introduction.............................................................................................................................17

 About the Project ....................................................................................................................................19

 Culture of Health................................................................................................................................19

 Overview of Health Measures............................................................................................................19

 Previous Research on Health Disparities in Appalachia....................................................................23

 The Appalachian Region..........................................................................................................................25

 Geographic Subregions......................................................................................................................25

 Rurality in Appalachia .......................................................................................................................26

 County Economic Status in Appalachia.............................................................................................27

 Visualization of the Health Measures: Quintiles, Thematic Maps, and Box Plots..................................29

 Quintiles.............................................................................................................................................29

 Thematic Maps...................................................................................................................................30

 Box Plots............................................................................................................................................31
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Domains...................................................................................................................................33

 Mortality ................................................................................................................................................ 35

 Heart Disease Deaths........................................................................................................................37

 Cancer Deaths...................................................................................................................................43

 Chronic Obstructive Pulmonary Disease Deaths..............................................................................49

 Injury Deaths.....................................................................................................................................55

 Stroke Deaths....................................................................................................................................61

 Diabetes Deaths ................................................................................................................................67

 Years of Potential Life Lost..............................................................................................................73

 Further Reading ................................................................................................................................79

 Morbidity ............................................................................................................................................... 81

 Physically Unhealthy Days...............................................................................................................83

 Mentally Unhealthy Days .................................................................................................................89

 HIV Prevalence.................................................................................................................................95

 Diabetes Prevalence ........................................................................................................................101

 Adult Obesity..................................................................................................................................107

 Further Reading ..............................................................................................................................113

 Behavioral Health ................................................................................................................................115

 Depression Prevalence ...................................................................................................................117

 Suicide............................................................................................................................................123

 Excessive Drinking ........................................................................................................................129

 Poisoning Deaths ...........................................................................................................................135

 Opioid Prescriptions.......................................................................................................................141

 Further Reading .............................................................................................................................147

 Child Health.........................................................................................................................................149

Infant Mortality............................................................................................................................ 151

Low Birth Weight ........................................................................................................................ 157

Teen Births................................................................................................................................... 163

Further Reading ........................................................................................................................... 169

 Community Characteristics.................................................................................................................. 171

Travel Time to Work ................................................................................................................... 173

Grocery Store Availability........................................................................................................... 179

Student-Teacher Ratio ................................................................................................................. 185
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Further Reading ........................................................................................................................... 191

 Lifestyle ............................................................................................................................................... 193

Physical Inactivity........................................................................................................................ 195

Smoking....................................................................................................................................... 201

Chlamydia Incidence ................................................................................................................... 207

Further Reading ........................................................................................................................... 213

 Health Care Systems............................................................................................................................ 215

 Primary Care Physicians.............................................................................................................. 217

 Mental Health Providers.............................................................................................................. 223

 Specialty Physicians..................................................................................................................... 229

 Dentists ........................................................................................................................................ 235

 Uninsured Population................................................................................................................... 241

 Heart Disease Hospitalizations .................................................................................................... 247

 Chronic Obstructive Pulmonary Disease Hospitalizations.......................................................... 253

 Further Reading ........................................................................................................................... 259 

 Quality of Care..................................................................................................................................... 261

 Electronic Prescribing.................................................................................................................. 263

 Mammogram Screenings ............................................................................................................. 269

 Diabetes Monitoring .................................................................................................................... 275

 Further Reading ........................................................................................................................... 281

 Social Determinants............................................................................................................................. 283

 Median Household Income .......................................................................................................... 285

 Poverty ......................................................................................................................................... 291

 Disability...................................................................................................................................... 297

 Education ..................................................................................................................................... 303

 Social Associations...................................................................................................................... 309

 Further Reading ........................................................................................................................... 315

Trends in Appalachian Health............................................................................................. 317

 Overview.............................................................................................................................................. 319

 Key Trends........................................................................................................................................... 320

 Years of Potential Life Lost......................................................................................................... 320
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 Cancer Mortality .......................................................................................................................... 323

 Heart Disease Mortality ............................................................................................................... 326

 Stroke Mortality........................................................................................................................... 329

 Infant Mortality............................................................................................................................ 332

 Office-Based Primary Care Physicians........................................................................................ 335

 Percentage of Households Living in Poverty............................................................................... 338

 Percentage of Adults with at Least a High School Diploma........................................................ 341

Appendices ........................................................................................................................... 345

A. Bibliography ........................................................................................................................... 347

B. Methodological and Technical Notes...................................................................................... 371
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GLOSSARY OF TERMS

Area Health 

Resources Files

The Area Health Resources Files (AHRF) are a family of health data 

resource products that draw from an extensive county-level database 

assembled annually from more than 50 sources. The Health Resources and 

Services Administration division of the United States Department of Health 

and Human Services manage the data. AHRF contains data on the healthcare 

workforce.

Age Adjusting Age adjusting is a technique that allows direct comparison of places that have 

different age distributions among their populations. See the Methodology 

section for more details. 

Appalachian Region The Appalachian Region is defined in the federal legislation from which the 

Appalachian Regional Commission derives its authority. The Region covers

205,000 square miles, and 420 counties in 13 states. It stretches more than 

1,000 miles from Mississippi to New York, and is home to more than 25 million 

people. 

Appalachian 

Regional 

Commission

The Appalachian Regional Commission (ARC) is a regional economic 

development agency that represents a partnership of federal, state, and local 

governments. Established by an act of Congress in 1965, ARC makes

investments that address the goals identified in the Commission's strategic 

plan, which include economic development, infrastructure improvement, and 

health improvement.

ARC Economic 

Index

ARC uses an index-based classification system to compare each county in the 

nation with national averages on three economic indicators: three-year 

average unemployment rates, per capita market income, and poverty rates. 

Based on that comparison, each Appalachian county is classified within one of 

five economic status designations—distressed, at-risk, transitional, 

competitive, or attainment.

American 

Community Survey 

(ACS)

The ACS is an ongoing survey conducted by the U.S. Census Bureau. This 

survey samples the population on a number of topics including population, 

age, education, home ownership, income, labor force, migration, and veteran 

status.

Behavioral Risk 

Factor Surveillance 

System

The Behavioral Risk Factor Surveillance System (BRFSS) is the nation's 

premier system of health-related telephone surveys that collects state-level

data about United States residents regarding their health-related risk 

behaviors, chronic health conditions, and use of preventive services. Many of 

the measures used in this report were derived from BRFSS data, via County 

Health Rankings.

Centers for Disease 

Control and 

Prevention

The Centers for Disease Control and Prevention (CDC) is the leading national 

public health protection agency in the United States. The CDC administers a 

number of data collection programs vital for health researchers, including the

WONDER data system, which contains detailed mortality information, and the 

Behavioral Risk Factor Surveillance System.
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County Health 

Rankings

The County Health Rankings & Roadmaps program is a collaboration between 

the Robert Wood Johnson Foundation and the University of Wisconsin 

Population Health Institute. The goals of the program are to build awareness 

of the multiple factors that influence health; provide a reliable, sustainable 

source of local data to communities to help them identify opportunities to 

improve their health; engage and activate local leaders from many sectors 

creating sustainable community change; and connect and empower 

community leaders working to improve health.

Economic Distress Distressed counties are the most economically depressed counties and rank in 

the worst 10 percent of the nation's counties. In fiscal year 2017, 84 

Appalachian counties qualify for distressed county status on the basis of low 

per capita income and high rates of poverty and unemployment.

Median The median is the value of the midpoint in a data set; it divides a data set into 

two equal parts. In a data set of 41 values, 20 values are above the median, 

and 20 values are below the median.

Morbidity Morbidity measures the frequency of any particular disease or illness within a 

population. 

Mortality In this report, mortality is used interchangeably with rate of death. Mortality 

indicators represent both disease-specific death rates, such as cancer 

mortality, and measures of all reasons for death, such as Years of Potential 

Life Lost.

PopulationWeighted Average

Rather than simply averaging values across counties, weighted averages 

account for the different sizes of the population in each county and weights the 

average accordingly. As a result, a population-weighted average will be 

influenced more by counties with large populations than those with small 

populations. The population-weighted average should be interpreted as the 

average for the people living in the area and not the average for counties in 

that area. See the Methodology section for more details.

Quintile Quintiles are groups of data points that have been divided into five equal parts 

from the dataset. The first quintile represents data points in the 20th percentile 

and below. The second quintile represents data points between the 20th and 

40th percentiles, etc.

Subregion ARC divides Appalachia into five subregions: Northern, North Central, Central, 

South Central, and Southern. These subregions may be referred to as 

Northern Appalachia, North Central Appalachia, etc. Counties within each 

subregion share similar characteristics, such as topography, demographics, 

and economics. 
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LIST OF FIGURES

Executive Summary

Figure 1: Map of the Appalachian Region....................................................................................................4

Introduction

Figure 2: Robert Wood Johnson Foundation Culture of Health Action Areas...........................................20

Figure 3: Appalachian Subregions..............................................................................................................25

Figure 4: Rurality by County in Appalachia...............................................................................................26

Figure 5: County Economic Status in Appalachia, FY 2017......................................................................28

Figure 6: Explanation of Thematic Maps ...................................................................................................30

Figure 7: How to Read a Box Plot..............................................................................................................31

Figure 8: Box Plot of Cancer Mortality Rates by Geography and Economic Status, 2008–2014 ..............32

Domains

Mortality

Figure 9: Map of Heart Disease Mortality Rates per 100,000 Population in the Appalachian Region, 

2008–2014 ..................................................................................................................................................39

Figure 10: Chart of Heart Disease Mortality Rates per 100,000 Population, 2008–2014 ..........................40

Figure 11: Map of Heart Disease Mortality Rates per 100,000 Population in the United States, 2008–2014

....................................................................................................................................................................41

Figure 12: Box Plot of Heart Disease Mortality Rates per 100,000 Population by Geography and 

Economic Status, 2008–2014......................................................................................................................42

Figure 13: Map of Cancer Mortality Rates per 100,000 Population in the Appalachian Region, 2008–2014

....................................................................................................................................................................45

Figure 14: Chart of Cancer Mortality Rates per 100,000 Population, 2008–2014 .....................................46

Figure 15: Map of Cancer Mortality Rates per 100,000 Population in the United States, 2008–2014.......47

Figure 16: Box Plot of Cancer Mortality Rates per 100,000 Population by Geography and Economic 

Status, 2008–2014.......................................................................................................................................48

Figure 17: Map of COPD Mortality Rates per 100,000 Population in the Appalachian Region, 2008–2014

....................................................................................................................................................................51

Figure 18: Chart of COPD Mortality Rates per 100,000 Population, 2008–2014......................................52

Figure 19: Map of COPD Mortality Rates per 100,000 Population in the United States, 2008–2014 .......53

Figure 20: Box Plot of COPD Mortality Rates per 100,000 Population by Geography and Economic 

Status, 2008–2014.......................................................................................................................................54

Figure 21: Map of Injury Mortality Rates per 100,000 Population in the Appalachian Region, 2008–2014

....................................................................................................................................................................57

Figure 22: Chart of Injury Mortality Rates per 100,000 Population, 2008–2014.......................................58

Figure 23: Map of Injury Mortality Rates per 100,000 Population in the United States, 2008–2014 ........59

Figure 24: Box Plot of Injury Mortality Rates per 100,000 Population by Geography and Economic 

Status, 2008–2014.......................................................................................................................................60

Figure 25: Map of Stroke Mortality Rates per 100,000 Population in the Appalachian Region, 2008–2014

....................................................................................................................................................................63

Figure 26: Chart of Stroke Mortality Rates per 100,000 Population, 2008–2014 ......................................64

Figure 27: Map of Stroke Mortality Rates per 100,000 Population in the United States, 2008–2014 .......65

Figure 28: Box Plot of Stroke Mortality Rates per 100,000 Population by Geography and Economic 

Status, 2008–2014.......................................................................................................................................66
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Figure 29: Map of Diabetes Mortality Rates per 100,000 Population in the Appalachian Region, 2008–

2014 ............................................................................................................................................................69

Figure 30: Chart of Diabetes Mortality Rates per 100,000 Population, 2008–2014...................................70

Figure 31: Map of Diabetes Mortality Rates per 100,000 Population in the United States, 2008–2014....71

Figure 32: Box Plot of Diabetes Mortality Rates per 100,000 Population by Geography and Economic 

Status, 2008–2014.......................................................................................................................................72

Figure 33: Map of Years of Potential Life Lost per 100,000 Population in the Appalachian Region, 2011–

2013 ............................................................................................................................................................75

Figure 34: Chart of Years of Potential Life Lost per 100,000 Population, 2011–2013 ..............................76

Figure 35: Map of Years of Potential Life Lost per 100,000 Population in the United States, 2011–2013..

....................................................................................................................................................................77

Figure 36: Box Plot of Years of Potential Life Lost per 100,000 Population by Geography and Economic 

Status, 2011–2013.......................................................................................................................................78

Morbidity

Figure 37: Map of Physically Unhealthy Days per Person per Month in the Appalachian Region, 2014..85

Figure 38: Chart of Physically Unhealthy Days per Person per Month, 2014............................................86

Figure 39: Map of Physically Unhealthy Days per Person per Month in the United States, 2014.............87

Figure 40: Box Plot of Physically Unhealthy Days per Person per Month by Geography and Economic 

Status, 2014.................................................................................................................................................88

Figure 41: Map of Mentally Unhealthy Days per Person per Month in the Appalachian Region, 2014....91

Figure 42: Chart of Mentally Unhealthy Days per Person per Month, 2014..............................................92

Figure 43: Map of Mentally Unhealthy Days per Person per Month in the United States, 2014 ...............93

Figure 44: Box Plot of Mentally Unhealthy Days per Person per Month by Geography and Economic 

Status, 2014.................................................................................................................................................94

Figure 45: Map of HIV Prevalence per 100,000 Population in the Appalachian Region, 2013.................97

Figure 46: Chart of HIV Prevalence per 100,000 Population, 2013...........................................................98

Figure 47: Map of HIV Prevalence per 100,000 Population in the United States, 2013 ............................99

Figure 48: Box Plot of HIV Prevalence per 100,000 Population by Geography and Economic Status, 2013

..................................................................................................................................................................100

Figure 49: Map of Percentage of Adults with Diabetes in the Appalachian Region, 2012 ......................103

Figure 50: Chart of Percentage of Adults with Diabetes, 2012 ................................................................104

Figure 51: Map of Percentage of Adults with Diabetes in the United States, 2012..................................105

Figure 52: Box Plot of Percentage of Adults with Diabetes by Geography and Economic Status, 2012.106

Figure 53: Map of Adult Obesity Prevalence in the Appalachian Region, 2012......................................109

Figure 54: Chart of Adult Obesity Prevalence, 2012................................................................................110

Figure 55: Map of Adult Obesity Prevalence in the United States, 2012.................................................111

Figure 56: Box Plot of Adult Obesity Prevalence by Geography and Economic Status, 2012 ................112

Behavioral Health

Figure 57: Map of Percentage of Medicare Beneficiaries that had a Depression-Related Office Visit in the 

Appalachian Region, 2012........................................................................................................................119

Figure 58: Chart of Percentage of Medicare Beneficiaries that had a Depression-Related Office Visit, 

2012 ..........................................................................................................................................................120

Figure 59: Map of Medicare Beneficiaries that had a Depression-Related Office Visit in the United States, 

2012 ..........................................................................................................................................................121

Figure 60: Box Plot of Percentage of Medicare Beneficiaries that had a Depression-Related Office Visit 

by Geography and Economic Status, 2012 ...............................................................................................122

Figure 61: Map of Suicide Rates per 100,000 Population in the Appalachian Region, 2008–2014.........125
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Figure 62: Chart of Suicide Rates per 100,000 Population, 2008–2014...................................................126

Figure 63: Map of Suicide Rates per 100,000 Population in the United States, 2008–2014....................127

Figure 64: Box Plot of Suicide Rates per 100,000 Population by Geography, and Economic Status, 2008–

2014 ..........................................................................................................................................................128

Figure 65: Map of Percentage of Residents that Report Excessive Drinking in the Appalachian Region, 

2014 ..........................................................................................................................................................131

Figure 66: Chart of Percentage of Residents that Report Excessive Drinking, 2014 ...............................132

Figure 67: Map of Percentage of Residents that Report Excessive Drinking in the United States, 2014..

..................................................................................................................................................................133

Figure 68: Box Plot of Percentage of Residents that Report Excessive Drinking by Geography and 

Economic Status, 2014..............................................................................................................................134

Figure 69: Map of Poisoning Mortality Rates per 100,000 Population in the Appalachian Region, 2008–

2014 ..........................................................................................................................................................137

Figure 70: Chart of Poisoning Mortality Rates per 100,000 Population, 2008–2014...............................138

Figure 71: Map of Poisoning Mortality Rates per 100,000 Population in the United States, 2008–2014..

..................................................................................................................................................................139

Figure 72: Box Plot of Poisoning Mortality Rates per 100,000 Population by Geography and Economic 

Status, 2008–2014.....................................................................................................................................140

Figure 73: Map of Opioid Prescriptions as a Percentage of Medicare Part D Claims in the Appalachian 

Region, 2013.............................................................................................................................................143

Figure 74: Chart of Opioid Prescriptions as a Percentage of Medicare Part D Claims, 2013 ..................144

Figure 75: Map of Opioid Prescriptions as a Percentage of Medicare Part D Claims in the United States, 

2013 ..........................................................................................................................................................145

Figure 76: Box Plot of Opioid Prescriptions as a Percentage of Medicare Part D Claims by Geography 

and Economic Status, 2013.......................................................................................................................146

Child Health

Figure 77: Map of Infant Mortality Rates in the Appalachian Region, 2008–2014 .................................153

Figure 78: Chart of Infant Mortality Rates, 2008–2014 ...........................................................................154

Figure 79: Map of Infant Mortality Rates in the United States, 2008–2014............................................ 155

Figure 80: Box Plot of Infant Mortality Rates by Geography and Economic Status, 2008–2014............156

Figure 81: Map of Percentage of Babies born with a Low Birth Weight in the Appalachian Region, 2007–

2013 ..........................................................................................................................................................159

Figure 82: Chart of Percentage of Babies born with a Low Birth Weight, 2007–2013............................160

Figure 83: Map of Percentage of Babies born with a Low Birth Weight in the United States, 2007–2013

..................................................................................................................................................................161

Figure 84: Box Plot of Percentage of Babies born with a Low Birth Weight by Geography and Economic 

Status, 2007–2013.....................................................................................................................................162

Figure 85: Map of Teen Birth Rates in the Appalachian Region, 2007–2013..........................................165

Figure 86: Chart of Births per 1,000 Females ages 15–19, 2007–2013....................................................166

Figure 87: Map of Teen Birth Rates in the United States, 2007–2013.....................................................167

Figure 88: Box Plot of Teen Birth Rates by Geography and Economic Status, 2007–2013 ....................168

Community Characteristics

Figure 89: Map of Average Travel Time to Work in the Appalachian Region, 2010–2014 ....................175

Figure 90: Chart of Average Travel Time to Work, 2010–2014 ..............................................................176

Figure 91: Map of Average Travel Time to Work in the United States, 2010–2014................................177
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Figure 92: Box Plot of Average Travel Time to Work by Geography and Economic Status, 2010–2014

..................................................................................................................................................................178

Figure 93: Map of Grocery Stores per 1,000 Population in the Appalachian Region, 2012 ....................181

Figure 94: Chart of Grocery Stores per 1,000 Population, 2012 ..............................................................182

Figure 95: Map of Grocery Stores per 1,000 Population in the United States, 2012................................183

Figure 96: Box Plot of Grocery Stores per 1,000 Population by Geography and Economic Status, 2012..

..................................................................................................................................................................184 

Figure 97: Map of Student-Teacher Ratios in the Appalachian Region, 2013–2014 ...............................187

Figure 98: Chart of Student-Teacher Ratios, 2013–2014 .........................................................................188

Figure 99: Map of Student-Teacher Ratios in the United States, 2013–2014...........................................189

Figure 100: Box Plot of Student-Teacher Ratios by Geography and Economic Status, 2013–2014........190

Lifestyle

Figure 101: Map of Percentage of Adults Physically Inactive in the Appalachian Region, 2012............197

Figure 102: Chart of Percentage of Adults Physically Inactive, 2012......................................................198

Figure 103: Map of Percentage of Adults Physically Inactive in the United States, 2012 .......................199

Figure 104: Box Plot of Percentage of Adults Physically Inactive by Geography and Economic Status,

2012 ..........................................................................................................................................................200

Figure 105: Map of Percentage of Adults that Smoke Cigarettes in the Appalachian Region, 2014 .......203

Figure 106: Chart of Percentage of Adults that Smoke Cigarettes, 2014 .................................................204

Figure 107: Map of Percentage of Adults that Smoke Cigarettes in the United States, 2014 ..................205

Figure 108: Box Plot of Percentage of Adults that Smoke Cigarettes by Geography and Economic Status, 

2014 ..........................................................................................................................................................206

Figure 109: Map of Chlamydia Incidence per 100,000 Population in the Appalachian Region, 2013 .. ..209

Figure 110: Chart of Chlamydia Incidence per 100,000 Population, 2013...............................................210

Figure 111: Map of Chlamydia Incidence per 100,000 Population in the United States, 2013................211

Figure 112: Box Plots of Chlamydia Incidence per 100,000 Population by Geography and Economic 

Status, 2013...............................................................................................................................................212

Health Care Systems

Figure 113: Map of Primary Care Physicians per 100,000 Population in the Appalachian Region, 2013..

................................................................................................................................................................. .219

Figure 114: Chart of Primary Care Physicians per 100,000 Population, 2013 .........................................220

Figure 115: Map of Primary Care Physicians per 100,000 Population in the United States, 2013 ..........221

Figure 116: Box Plot of Primary Care Physicians per 100,000 Population by Geography and Economic 

Status, 2013...............................................................................................................................................222

Figure 117: Map of Mental Health Providers per 100,000 Population in the Appalachian Region, 2015.

..................................................................................................................................................................225

Figure 118: Chart of Mental Health Providers per 100,000 population, 2015..........................................226

Figure 119: Map of Mental Health Providers per 100,000 Population in the United States, 2015...........227

Figure 120: Box Plot of Mental Health Providers per 100,000 Population by Geography and Economic 

Status, 2015...............................................................................................................................................228

Figure 121: Map of Specialty Physicians per 100,000 Population in the Appalachian Region, 2013......231

Figure 122: Chart of Specialty Physicians per 100,000 Population, 2013................................................232

Figure 123: Map of Specialty Physicians per 100,000 Population in the United States, 2013.................233

Figure 124: Box Plot of Specialty Physicians per 100,000 Population by Geography and Economic Status, 

2013 ..........................................................................................................................................................234

Figure 125: Map of Dentists per 100,000 Population in the Appalachian Region, 2014 .........................237
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Figure 126: Chart of Dentists per 100,000 Population, 2014 ...................................................................238

Figure 127: Map of Dentists per 100,000 Population in the United States, 2014.....................................239

Figure 128: Box Plot of Dentists per 100,000 Population by Geography and Economic Status, 2014....240

Figure 129: Map of Uninsurance Rate for People under Age 65 in the Appalachian Region, 2013 ........243

Figure 130: Chart of Uninsurance Rate for People under Age 65, 2013 ..................................................244

Figure 131: Map of Uninsurance Rate for People under Age 65 in the United States, 2013 ...................245

Figure 132: Box Plot of Uninsurance Rate for People under Age 65 by Geography and Economic Status, 

2013 ..........................................................................................................................................................246

Figure 133: Map of Heart Disease Hospitalizations per 1,000 Medicare Beneficiaries in the Appalachian 

Region, 2012.............................................................................................................................................249

Figure 134: Chart of Heart Disease Hospitalizations per 1,000 Medicare Beneficiaries, 2012................250

Figure 135: Map of Heart Disease Hospitalizations per 1,000 Medicare Beneficiaries in the United States, 

2012 ..........................................................................................................................................................251

Figure 136: Box Plot of Heart Disease Hospitalizations per 1,000 Medicare Beneficiaries by Geography 

and Economic Status, 2012.......................................................................................................................252

Figure 137: Map of COPD Hospitalizations per 1,000 Medicare Beneficiaries in the Appalachian Region, 

2012 ..........................................................................................................................................................255

Figure 138: Chart of COPD Hospitalizations per 1,000 Medicare Beneficiaries, 2012 ...........................256

Figure 139: Map of COPD Hospitalizations per 1,000 Medicare Beneficiaries in the United States, 2012

..................................................................................................................................................................257

Figure 140: Box Plot of COPD Hospitalizations per 1,000 Medicare Beneficiaries by Geography and 

Economic Status, 2012............................................................................................... 258

Quality of Care

Figure 141: Map of Percentage of Physicians that e-Prescribe in the Appalachian Region, 2014...........265

Figure 142: Chart of Percentage of Physicians that e-Prescribe, 2014 .....................................................266

Figure 143: Map of Percentage of Physicians that e-Prescribe in the United States, 2014 ......................267

Figure 144: Box Plot of Percentage of Physicians that e-Prescribe by Geography and Economic Status, 

2014 ..........................................................................................................................................................268

Figure 145: Map of Percentage of Medicare-covered Women Ages 67 to 69 with a Recent Mammogram 

Screening in the Appalachian Region, 2013.............................................................................................271

Figure 146: Chart of Percentage of Medicare-covered Women Ages 67 to 69 with a Recent Mammogram 

Screening, 2013.........................................................................................................................................272

Figure 147: Map of Percentage of Medicare-covered Women Ages 67 to 69 with a Recent Mammogram 

Screening in the United States, 2013 ........................................................................................................273

Figure 148: Box Plot of Percentage of Medicare-covered Women Ages 67 to 69 with a Recent 

Mammogram Screening by Geography and Economic Status, 2013........................................................274

Figure 149: Map of Percentage of Medicare Patients Ages 65 to 75 with an HbA1C Screening in the Past 

Year in the Appalachian Region, 2012 .....................................................................................................277

Figure 150: Chart of Percentage of Medicare Patients Ages 65 to 75 with an HbA1C Screening in the Past 

Year, 2012.................................................................................................................................................278

Figure 151: Map of Percentage of Medicare Patients Ages 65 to 75 with an HbA1C Screening in the Past 

Year in the United States, 2012 ................................................................................................................279

Figure 152: Box Plot of Percentage of Medicare Patients Ages 65 to 75 with an HbA1C Screening in the 

Past Year by Geography and Economic Status, 2012...............................................................................280
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Social Determinants

Figure 153: Map of Median Household Income in the Appalachian Region, 2010–2014 ...................... 287

Figure 154: Chart of Median Household Income, 2010–2014 .................................................................288

Figure 155: Map of Median Household Income in the United States, 2010–2014...................................289

Figure 156: Box Plot of Median Household Income by Geography and Economic Status, 2010-2014...290

Figure 157: Map of Household Poverty Rates in the Appalachian Region, 2014 ....................................293

Figure 158: Chart of Household Poverty Rates, 2014 ..............................................................................294

Figure 159: Map of Household Poverty Rates in the United States, 2014................................................295

Figure 160: Box Plot of Household Poverty Rates by Geography and Economic Status, 2014...............296

Figure 161: Map of Percentage of Residents Receiving Disability Benefits in the Appalachian Region, 

2014 ..........................................................................................................................................................299

Figure 162: Chart of Percentage of Residents Receiving Disability Benefits, 2014 ................................300

Figure 163: Map of Percentage of Residents Receiving Disability Benefits in the United States, 2014...

..................................................................................................................................................................301

Figure 164: Box Plot of Percentage of Residents Receiving Disability Benefits by Geography and 

Economic Status, 2014..............................................................................................................................302

Figure 165: Map of Percentage of Adults with Some College Education in the Appalachian Region, 

2010–2014 ................................................................................................................................................305

Figure 166: Chart of Percentage of Adults with Some College Education, 2010–2014...........................306

Figure 167: Map of Percentage of Adults with Some College Education in the United States, 2010-2014

..................................................................................................................................................................307

Figure 168: Box Plot of Percentage of Adults with Some College Education by Geography and Economic 

Status, 2010-2014 .....................................................................................................................................308

Figure 169: Map of Social Organizations per 10,000 Population in the Appalachian Region, 2013 .......311

Figure 170: Chart of Social Organizations per 10,000 Population, 2013 .................................................312

Figure 171: Map of Social Organizations per 10,000 Population in the United States, 2013 ..................313

Figure 172: Box Plot of Social Organizations per 10,000 Population by Geography and Economic Status, 

2013 ..........................................................................................................................................................314

Trends

Figure 173: Improvements in YPLL in the United States and Appalachia, 1989–1995 to 2008–2014....320

Figure 174: Map of Years of Potential Life Lost per 100,000 Population in the Appalachian Region, 

1989–1995 and 2008–2014.......................................................................................................................321

Figure 175: Improvements in Cancer Mortality in the United States and Appalachia, 1989–1995 to 2008–

2014 ..........................................................................................................................................................323

Figure 176: Map of Cancer Mortality Rates per 100,000 Population in the Appalachian Region, 1989–

1995 and 2008–2014..................................................................................................324

Figure 177: Improvements in Heart Disease Mortality in the United States and Appalachia, 1989–1995 to 

2008–2014 ................................................................................................................................................326

Figure 178: Map of Heart Disease Mortality Rates per 100,000 Population in the Appalachian Region, 

1989–1995 and 2008–2014.......................................................................................................................327

Figure 179: Improvements in Stroke Mortality in the United States and Appalachia, 1989–1995 to 2008–

2014 ..........................................................................................................................................................329

Figure 180: Map of Stroke Mortality Rates per 100,000 Population in the Appalachian Region, 1989–

1995 to 2008–2014 ...................................................................................................................................330

Figure 181: Improvements in Infant Mortality in the United States and Appalachia, 1989–1995 to 2008–

2014 ....................................................................................................................332

Figure 182: Map of Infant Mortality Rates in the Appalachian Region, 1989–1995 and 2008–2014.....333
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Figure 183: Improvements in Office-Based Primary Care Physicians in the United States and Appalachia, 

1990 to 2013 .............................................................................................................................................335

Figure 184: Map of Primary Care Physicians per 100,000 Population in the Appalachian Region, 1990 

and 2013....................................................................................................................................................336

Figure 185: Changes in Household Poverty Rates in the United States and Appalachia, 1995 to 2014 ..338

Figure 186: Map of Percentage of Household Poverty Rates in the Appalachian Region, 1995 and 2014

..................................................................................................................................................................339

Figure 187: Improvements in the Percentage of Adults with a High School Diploma in the United States 

and Appalachia, 1990 to 2013 ..................................................................................................................341

Figure 188: Map of Percentage of Adults with at least a High School Diploma in the Appalachian Region, 

1990 and 2013.........................................................................................................342

Methodological and Technical Notes

Figure 189: Example of Weighting Counties for Smoothing Based on Distance.....................................375

Figure 190: Components of a Box Plot.............................................................................380
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LIST OF TABLES

Executive Summary

Table 1: Distributions of Mortality Rates among National Quintiles for Appalachian Counties.................6

Table 2: Distributions of Morbidity Indicators among National Quintiles for Appalachian Counties.........7

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

Counties........................................................................................................................................................8

Table 4: Distributions of Child Health Indicators among National Quintiles for Appalachian Counties.....9

Table 5: Distributions of Community Characteristics Indicators among National Quintiles for 

Appalachian Counties.................................................................................................................................10

Table 6: Distributions of Lifestyle Indicators among National Quintiles for Appalachian Counties........11

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

Counties......................................................................................................................................................12

Table 8: Distributions of Quality of Care Indicators among National Quintiles for Appalachian Counties

....................................................................................................................................................................13

Table 9: Distributions of Social Determinants Indicators among National Quintiles for Appalachian 

Counties......................................................................................................................................................14

Table 10: Percentage change in selected measures, the United States and Appalachia..............................14

Introduction

Table 11: Health Measures, by Domain......................................................................................................22

Table 12: Health Measures, by RWJF Culture of Health Action Area.......................................................23

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

Appalachian Counties.................................................................................................................................29

Domains

Mortality

Table 14: Distribution of Heart Disease Mortality Rates per 100,000 Population among National Quintiles 

for Appalachian Counties ...........................................................................................................................42

Table 15: Distribution of Cancer Mortality Rates per 100,000 Population among National Quintiles for 

Appalachian Counties.................................................................................................................................48

Table 16: Distribution of COPD Mortality Rates per 100,000 Population among National Quintiles for 

Appalachian Counties.................................................................................................................................54

Table 17: Distribution of Injury Mortality Rates per 100,000 Population among National Quintiles for 

Appalachian Counties.................................................................................................................................60

Table 18: Distribution of Stroke Mortality Rates per 100,000 Population among National Quintiles for 

Appalachian Counties.................................................................................................................................66

Table 19: Distribution of Diabetes Mortality Rates per 100,000 Population among National Quintiles for 

Appalachian Counties.................................................................................................................................72

Table 20: Distribution of Years of Potential Life Lost per 100,000 Population among National Quintiles 

for Appalachian Counties ...........................................................................................................................78
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Morbidity

Table 21: Distribution of Physically Unhealthy Days per Person per Month among National Quintiles for 

Appalachian Counties.................................................................................................................................88

Table 22: Distribution of Mentally Unhealthy Days per Person per Month among National Quintiles for 

Appalachian Counties.................................................................................................................................94

Table 23: Distribution of HIV Prevalence per 100,000 Population among National Quintiles for 

Appalachian Counties...............................................................................................................................100

Table 24: Distribution of Percentage of Adults with Diabetes among National Quintiles for Appalachian 

Counties....................................................................................................................................................106

Table 25: Distribution of Adult Obesity Prevalence among National Quintiles for Appalachian Counties

..................................................................................................................................................................112

Behavioral Health

Table 26: Distribution of Medicare Beneficiaries that had a Depression-Related Office Visit among 

National Quintiles for Appalachian Counties...........................................................................................122

Table 27: Distribution of Suicide Rates per 100,000 Population among National Quintiles for 

Appalachian Counties...............................................................................................................................128

Table 28: Distribution of Percentage of Residents that Report Excessive Drinking among National 

Quintiles for Appalachian Counties..........................................................................................................134

Table 29: Distribution of Poisoning Mortality Rates among National Quintiles for Appalachian Counties

..................................................................................................................................................................140

Table 30: Distribution of Opioid Prescriptions as a Percentage of Medicare Part D Claims among 

National Quintiles for Appalachian Counties...........................................................................................146

Child Health

Table 31: Distribution of Infant Mortality Rates among National Quintiles for Appalachian Counties..156

Table 32: Distribution of Low Birth Weight Incidence among National Quintiles for Appalachian 

Counties....................................................................................................................................................162

Table 33: Distribution of Teen Birth Rates among National Quintiles for Appalachian Counties...........168

Community Characteristics

Table 34: Distribution of Average Travel Time to Work among National Quintiles for Appalachian 

Counties....................................................................................................................................................178

Table 35: Distribution of Grocery Stores per 1,000 Population among National Quintiles for Appalachian 

Counties....................................................................................................................................................184

Table 36: Distribution of Student-Teacher Ratios among National Quintiles for Appalachian Counties..

..................................................................................................................................................................190

Lifestyle

Table 37: Distribution of Percentage of Adults Physically Inactive among National Quintiles for 

Appalachian Counties...............................................................................................................................200

Table 38: Distribution of Percentage of Adults that Smoke Cigarettes among National Quintiles for 

Appalachian Counties...............................................................................................................................206

Table 39: Distribution of Chlamydia Incidence per 100,000 Population among National Quintiles for 

Appalachian Counties...............................................................................................................................212
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Health Care Systems

Table 40: Distribution of Primary Care Physicians per 100,000 Population among National Quintiles for 

Appalachian Counties...............................................................................................................................222

Table 41: Distribution of Mental Health Providers per 100,000 Population among National Quintiles for 

Appalachian Counties...............................................................................................................................228

Table 42: Distribution of Specialty Physicians per 100,000 Population among National Quintiles for 

Appalachian Counties...............................................................................................................................234

Table 43: Distribution of Dentists per 100,000 Population among National Quintiles for Appalachian 

Counties....................................................................................................................................................240

Table 44: Distribution of Uninsurance Rate for People under Age 65 among National Quintiles for 

Appalachian Counties...............................................................................................................................246

Table 45: Distribution of Heart Disease Hospitalization Rates per 1,000 Medicare Beneficiaries among 

National Quintiles for Appalachian Counties...........................................................................................252

Table 46: Distribution of COPD Hospitalization Rates per 1,000 Medicare Beneficiaries among National 

Quintiles for Appalachian Counties..........................................................................................................258

Quality of Care

Table 47: Distribution of Percentage of Physicians that e-Prescribe among National Quintiles for 

Appalachian Counties...............................................................................................................................268

Table 48: Distribution of Percentage of Medicare-covered Women Ages 67 to 69 with a Recent 

Mammogram Screening among National Quintiles for Appalachian Counties........................................274

Table 49: Distribution of Percentage of Medicare Patients Ages 65 to 75 with an HbA1C Screening in the 

Past Year among National Quintiles for Appalachian Counties................................................280

Social Determinants

Table 50: Distribution of Median Household Income among National Quintiles for Appalachian Counties

..................................................................................................................................................................290

Table 51: Distribution of Household Poverty Rates among National Quintiles for Appalachian Counties

..................................................................................................................................................................296

Table 52: Distribution of Percentage of Residents Receiving Disability Benefits among National Quintiles 

for Appalachian Counties .........................................................................................................................302

Table 53: Distribution of Percentage of Adults with Some College Education among National Quintiles 

for Appalachian Counties .........................................................................................................................308

Table 54: Distribution of Social Organizations per 10,000 Population among National Quintiles for 

Appalachian Counties...............................................................................................................................314

Trends

Table 55: Change in Years of Potential Life Lost per 100,000 Population, 1989–1995 and 2008–2014.322

Table 56: Distribution of YPLL Rates among National Quintiles for Appalachian Counties..................322

Table 57: Change in Cancer Mortality Rates per 100,000 Population, 1989–1995 and 2008–2014........324

Table 58: Distribution of Cancer Mortality Rates among National Quintiles for Appalachian Counties 325

Table 59: Change in Heart Disease Mortality Rates per 100,000 Population, 1989–1995 and 2008–2014..

..................................................................................................................................................................327
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Table 60: Distribution of Heart Disease Mortality Rates among National Quintiles for Appalachian 

Counties....................................................................................................................................................328

Table 61: Change in Stroke Mortality Rates per 100,000 population, 1989–1995 and 2008–2014.........330

Table 62: Distribution of Stroke Mortality Rates among National Quintiles for Appalachian Counties..331

Table 63: Change in Infant Mortality Rates, 1989–1995 and 2008–2014................................................333

Table 64: Distribution of Infant Mortality Rates among National Quintiles for Appalachian Counties..334

Table 65: Change in Primary Care Physicians per 100,000 population, 1990 to 2013 ............................337

Table 66: Distribution of Primary Care Physicians among National Quintiles for Appalachian Counties

..................................................................................................................................................................337

Table 67: Change in Household Poverty Rates, 1995 to 2014 .................................................................339

Table 68: Distribution of Household Poverty Rates among National Quintiles for Appalachian Counties

..................................................................................................................................................................340

Table 69: Change in Percentage of Adults with at least a High School Diploma, 1990 and 2009–2013..343

Table 70: Distribution of Percentage of Adults with at least a High School Diploma among National 

Quintiles for Appalachian Counties.......................................................................................................... 343

Methodological and Technical Notes

Table 71: Year 2000 Standard Million Population for the United States.................................................372

Table 72: Comparison of Crude and Age-Adjusted Mortality Rates for Utah and Maine ......................373

Table 73: Comparison of Calculated Age-Adjusted Rates with CDC Wonder Reported Rates...............373

Table 74: Sample County Illustration of Augmentation for Suppressed Data..........................................377

Table 75: Age-Adjusted Step for Spatial Adjustment...............................................................................377

Table 76: USDA Twelve County Classification System..........................................................................379
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