Introduction
This study was commissioned
by the Appalachian Regional Commission in order
to compile standardized, baseline information regarding
health disparities in the region. Health disparities
result from differences in the incidence, prevalence,
mortality, and burden of diseases and other adverse
health conditions that exist among specific population
groups. This study provides baseline information
needed to assess health disparities in the region,
to investigate causes of regional and local disparities,
and to aid in developing targeted interventions
aimed at reducing disparities and improve the overall
health of the region.
The data and analyses presented
in this report identify significant disparities
in health status between the Appalachian region
and non-Appalachian U.S. ,
with the Appalachian region generally experiencing
more adverse health outcomes. However, not all areas
or population subgroups within the Appalachian region
experience the same level of adverse health status.
The reasons for geographic and demographic variability
in health status are not clear; however a number
of factors may contribute to geographic and demographic
disparities in health status, including socioeconomic
condition, access to medical care resources, and
variability in the prevalence of high-risk behaviors.
Significant diversity within the region with regards
to these factors may help to explain observed disparities
in health status.
In order to develop effective
programs and policies to reduce and eliminate health
disparities, it is necessary to understand the extent
of disparities in health status as well as potential
contributing factors. This report provides critical
data and analyses documenting health disparities
in the Appalachian region (as well as the non-Appalachian
U.S. )
and aids efforts to develop interventions that can
be targeted to areas with the greatest need. In
addition, this report provides a basis for understanding
factors that contribute to geographic and demographic
variability in health status in the Appalachian
region.
Health Disparities
Significant improvements in the overall
health of the population in the United
States have been realized over
the last four decades. In general, improvements
in health may be attributable to a combined effect
of improved living standards, advancements in medical
treatment, improved access to medical care and resources,
and increased awareness about health risks in the
general population. However improvements in health
outcomes have not been realized by all segments
of the population and have resulted in significant
disparities along a number
of dimensions including gender, ethnicity, socioeconomic
status, and geographic location.
The
National Institutes of Health (NIH) health disparities
definition is:
"Health
disparities are differences in the incidence, prevalence,
mortality, and burden of diseases and other adverse
health conditions that exist among specific population
groups in the United
States ."
(http://healthdisparities.nih.gov/whatare.html)
Disparities in health exert an enormous
burden on the health care community and on society.
Variations in social, cultural, behavioral, biologic,
genetic, and environmental factors contribute to
differences in health among population subgroups
and geographic locations. Among factors that are
likely to contribute to disparities in health, access
to medical care and quality of medical care are
critical.
Reducing health disparities was a
goal of the Healthy People 2000 objectives. Healthy
People 2010 objectives have been substantially expanded
to include eliminating health disparities, and this
represents one of the most significant challenges
for the nation. One of the key elements to the successful
reduction of disparities along all socio-demographic
and geographic dimensions is developing an understanding
of the nature and extent of disparities.
The Appalachian region has endured significant
excesses in adverse health outcomes. In general,
the Appalachian region has lagged economically behind
other parts of the U.S. Relatively high levels of
unemployment, low regional incomes, and educational
deficits continue to contribute to a lower standard
of living than enjoyed in many areas of the U.S.
However, Appalachia also represents
significant levels of socioeconomic diversity. For
example, metropolitan areas in the region have more
diversified economies, higher per capita incomes,
and greater access to medical care than non-metropolitan
areas (Barnett, et al). Local socioeconomic
differences within the Appalachian region are likely
to be key contributors to disparities in health
outcomes with those areas having diminished access
to social, economic, and medical care resources
experiencing more adverse outcomes. However, detailed
data which describe the extent and nature of these
disparities has been lacking.
The Appalachian
region and the A.R.C.
The Appalachian Regional
Commission (ARC) is a federal-state partnership
established in 1965 by the Appalachian Regional
Development Act to promote economic and social development
of the Appalachian Region. With a total population
of 22.8 million, the Appalachian Region includes,
as amended in 2002, 410 counties (when this study
was commissioned in October of 2001, the ARC designated
region consisted of 406 counties). The ARC designated
region includes all of West
Virginia and parts of 12 other states and extends
more than a thousand miles from the southern tier
of New York to northeast Mississippi.
Appalachia 's population is geographically
distributed across the urban-rural spectrum, from
large urban areas in metropolitan counties to small,
very remote counties lacking even small urban concentrations.
Sixty percent of the population live in metropolitan
counties, twenty-five percent live in counties adjacent
to metropolitan counties, while the balance of the
population live in more remote, rural locations.
For 38 years, the
Commission has funded a wide range of programs in
the Region, including highway corridors; community
water and sewer facilities and other physical infrastructure;
health, education, and human resource development;
economic development programs; and local capacity
building and leadership development. In FY 2003,
the Commission's definitions of economic development
levels designates 121 counties as distressed because
of high rates of poverty and unemployment and low
rates of per capita market income compared to national
averages; 259 counties were designated transitional
(42 of these transitional counties may be characterized
as "at-risk"), with higher than average rates of
poverty and unemployment and lower per capita market
income; 21 counties have nearly achieved parity
with national socioeconomic norms and are now designated
as competitive and; 9 counties have reached or exceeded
national norms and are now designated as attainment
counties.
Organization of
Report
Section I of this report
describes regional disparities in mortality from
leading causes of death between the Appalachian
region and the non-Appalachia United
States . Regional death rates
as well as county-level death rates were generated
for eight population subgroups; white and black
men and women ages 35 to 64 and 65 and older. County-level
maps of death rates are presented for all counties
in the coterminous U.S. and separately
for the Appalachian region. This section highlights
regional and county-level disparities in death rates.
Section II examines county-level rates of hospitalizations
from leading causes of illness for selected counties
in the Appalachian region. Hospitalization rates
are presented by county for six population subgroups:
all persons ages 35 to 64 and 65 and older, and
men and women ages 35 to 64 and 65 and older. Section
III describes general socioeconomic conditions among
Appalachian counties. Section IV examines leading
health indictors among behavioral risks. Section
V documents medical care resources in the Appalachian
region. Section VI provides an overview of the study
results and suggests several avenues for further
research.
Summary of Findings
An Analysis of Disparities
in Health Status and Access to Medical Care in the
Appalachian Region shows that significant health
disparities persist in the Appalachian region. The
region as a whole suffers considerable excess in
mortality from leading causes of death when compared
to the non-Appalachian U.S.
Furthermore, there is a high degree of within-region
variability in both the rates of mortality and hospitalization.
Many Appalachian counties with the most adverse
health outcomes correlate geographically with socioeconomic
characteristics, behavioral risk profiles, and available
medical care resources. However, there does not
appear to be a consistent relationship between all
factors combined for individual counties. It appears
that reasons for disparities in health outcomes
are highly variable and localized. Identifying the
causes of inconsistencies may help in developing
effective interventions and policy at the local
level.
- Overall the Appalachian region experiences excesses
in mortality from many of the major causes of death
and illness relative to the non-Appalachian U.S.
- To clarify the extent
and nature of regional excesses, analyses have
been conducted for eight demographic subgroups
for leading causes of death and illness; white
and black men and women ages 35 to 64 and 65 and
older.
- County-level analyses
have also been conducted in order to identify
disparities within the Appalachian region and
highlight clusters of counties that exhibit both
favorable and adverse health outcomes in the region.
- Additional data is examined
which may help to explain observed disparities
including, socioeconomic conditions, behavioral
risks, and available medical care resources.
- Together these data provide
a detailed account of health status in the Appalachian
region and provide evidence for targeted interventions
as well as avenues for further research.
- These data suggest that
variations in health status within Appalachian
are, to a large extent, highly localized and therefore
achieving Healthy People 2010 objectives will
require intervention at the local level.
I. Mortality
Mortality statistics
provide the most comprehensive source of information
available for examining public health outcomes among
population subgroups and/or geographic areas. The
analyses conducted in this study help to situate
the mortality experience of the Appalachian region
with the rest of the United
States . The specific causes
of death that were analyzed are heart disease, cancer(s),
cerebrovascular disease (stroke), chronic obstructive
pulmonary disease and allied conditions, diabetes,
accidental deaths, deaths from motor vehicle accidents,
suicide, and infant mortality. The study population
consisted of black and white men and women who resided
in the United
States during the period 1990-1997.
Each of these sub-groups was divided into two age
categories; 35 to 64 and 65 and older. Deaths which
occur in the 35 to 64 age-groups are considered
premature and preventable.
Regional Death Rates from Specific Causes, U.S. and Appalachia,
1990-1997 – Persons Ages 65 and Older
The Appalachian region
as a whole experiences excess mortality compared
to the non-Appalachian U.S. Among the causes
of death examined in this study, Appalachian populations
suffer the most significant excesses in heart disease
mortality, the leading cause of death in the U.S.
There are, however, considerable differences in
the burden of mortality among age/gender/ethnic
groups. In addition, the Appalachian region suffers
an excess in premature deaths (among persons ages
35 to 64) from heart disease, all cancers combined,
lung cancer, colorectal cancer, chronic obstructive
pulmonary disease, diabetes, and motor vehicle accidents,
relative to comparable non-Appalachian U.S.
population. All Cause death rates are consistently
higher among Appalachian population subgroups compared
with U.S rates, with the exception of black men
ages 35 to 64 and black women ages 65 and older.
County-level Mortality Rates
The analyses of county-level
mortality rates are intended to identify geographic
disparities in mortality in the Appalachian region,
highlight specific areas in the region that experience
the most adverse health outcomes, and aid in the
development of tailored intervention strategies
for reducing adverse health outcomes and disparities
in Appalachia. County-level mortality analyses for
the coterminous U.S.
allow comparisons between counties in the Appalachian
region and non-Appalachian U.S.
Mortality
from all causes
exhibits some clear geographic patterns that are
fairly consistent among the demographic subgroups.
The geographic patterns are nearly identical for
white men and women in both age categories with
high rate areas concentrated in the Central Appalachian
counties in portions of Eastern Kentucky, Southern
Ohio, Southern West Virginia, and Western
Virginia. Additional high-rate counties appear in
the Southern portion of the region. The geographic
patterns for black men and women are less consistent
although there are similarities with the distribution
for white men and women.
County-level
trends in all-cause mortality have been estimated over the period 1985-1997. There
are substantial differences in the trends among
race/ethnic, gender, and age groups. For white men
in both age groups the trends of all-cause mortality
are overwhelmingly positive with the greatest number
of counties experiencing moderate declines over
the study period. However, many counties have experienced
negligible change (arguably a negative outcome).
The majority of counties
experiencing moderate increases among white men
occur in the counties of Central and Southern Appalachia. Mortality trends for
white women are less positive, particularly among
elderly white women where the majority of counties
experienced either negligible change or moderate
increases. The majority of counties for which trends
can be estimated for black men and women have experienced
moderate declines in disparities, with some counties
in the south experiencing adverse trends.
Heart Disease Mortality in Appalachia
Both in the Appalachian
region and the non-Appalachian U.S. ,
death rates from heart disease rank first among
causes of death, with a marked disparity in Appalachia.
In general, high death rates from heart disease
are predominant in the central and southern portions
of the Appalachian region among all demographic
subgroups.
The dominant trends
since 1985 for all population subgroups suggest
moderate to strong declines in heart disease mortality
over the study period. However, in each state several
counties have experienced moderate increases and
a few have experienced strong increases.
Cancer Mortality in Appalachia
Both
in the Appalachian region and the non-Appalachian
U.S. , death rates from
all cancers rank first among death rates used in
this analysis for white and black women ages 35
to 64. For
white and black men ages 35 to 64 cancer death rates
rank second. Among the elderly, Appalachian death
rates from all cancers rank second for all demographic
groups in both the Appalachian region and the non-Appalachian
U.S.
In general, high death rates from all cancers are
predominant in the central portion of the Appalachian
region among all demographic subgroups. However,
there is considerable variation among demographic
groups. For example, for elderly white women, high
cancer death rates occur in Eastern Kentucky, Southern
West Virginia, and Southeastern Ohio in addition
to Southwestern Pennsylvania and Southern New York.
The county-level trends
for cancer mortality since 1985 indicate significant
variability in the mortality trends among counties
in the Appalachian region. Perhaps the most striking
trend is the number of counties that have experienced
moderate to strong increases in mortality from all
cancers.
Breast Cancer Mortality in Appalachia
With
the exception of white women ages 35 to 64, breast
cancer death rates used in this analysis suggest
an excess of breast cancer mortality among Appalachian
women compared with the Non-Appalachian U.S. While
the magnitude of the death rates is larger for black
women of both age-groups, there appears to be greater
disparity in the county-level rates among white
women of both age groups.
Colorectal Cancer Mortality in Appalachia
There
appears to be a north to south gradient of disparities
in colorectal cancer death rates for both white
men and women of both age groups. The data for black
men and women are very limited for both age groups,
although there do appear to be a few clusters, particularly
in western Pennsylvania and eastern Tennessee, and
for elderly black women in southern West Virginia.
Lung Cancer Mortality in Appalachia
In general the region
has slightly higher lung cancer death rates for
all demographic groups when compared to the rest
of the nation, although there is considerable variation
in the geographic distribution of rates among the
different demographic subgroups. Central Appalachia
exhibits a strong clustering of higher rates for
white men ages 35-64 and elderly men, with clusters
of higher rates in northeast Mississippi,
northwest Alabama, and northwest
Georgia .
White women exhibit higher rates in central Appalachia,
as well a clustering among elderly women in northern
Pennsylvania and the southern
tier of New
York. Black men and women of both age groups show
clustering in counties around Pittsburgh, southern West
Virginia, eastern Tennessee,
particularly surrounding Chattanooga, concentrations in northeast Mississippi
and northern Georgia
and several counties in western North and South
Carolina. Elevated rates are also found in Black
women of both age groups in the two western-most
counties of New York.
Stroke Mortality in Appalachia
Both in the Appalachian
region and the non-Appalachian U.S. ,
death rates from stroke rank fourth among death
rates used in this analysis for white and black
men of both age groups and third among white and
black women of both age groups. In general, high
death rates from stroke are predominant in the southern
portion of the Appalachian region among all demographic
subgroups. This pattern is consistent with the history
of the 'Stroke Belt'. For the most part, county
level trends show that most counties have continued
the historic trend of decline. There are a number
of counties, throughout the Region, however, where
rates are increasing, but Northern
Pennsylvania seems to exhibit a disproportionate
number of increases for elderly white men.
Chronic Obstructive Pulmonary Disease (COPD)
Mortality in Appalachia
Both
in the Appalachian region and the non-Appalachian
U.S. ,
death rates from all COPD rank fifth among death
rates used in this analysis for white and black
men of both age groups. For white and black women
of both age groups COPD death rates rank fourth.
In general, high death rates from COPD are predominant
in the central portion of the Appalachian Region
among white population groups. There appear to be
consistently high rates of COPD mortality among
counties in the Western Carolinas and in Alabama among all black population groups.
Perhaps the most striking feature of the trend is
the number of counties that have experienced moderate
to strong increases in mortality from COPD.
Accidental Mortality in Appalachia
Both in the Appalachian
region and the non-Appalachian U.S. ,
death rates from accidental causes rank third among
death rates used in this analysis for white and
black men ages 35 to 64. In general, high death
rates from accidental causes are predominant in
the southern portion of the Appalachian region among
all demographic subgroups. The majority of counties
have experienced either moderate declines or negligible
change for all demographic subgroups over the study
period.
Motor Vehicle Accident Mortality in Appalachia
Both
in the Appalachian region and the non-Appalachian
U.S., death rates attributable to motor vehicle
accidents rank fifth among white men ages 35 to
64 and ninth among white women ages 35 to 64. In
Appalachia and the motor vehicle death rate is seventh
among black men ages 35 to 64 and eighth among younger
black men in the non-Appalachian U.S. Motor vehicle
death rates rank last among black women ages 35
to 64 in both the Appalachian and non-Appalachian
regions as well as among all elderly demographic
groups. In general, there appears to be a south-north
gradient with higher death rates occurring primarily
in the southern portions of the region.
Diabetes Mortality in Appalachia
Both in the Appalachian
region and the non-Appalachian U.S. ,
death rates attributable to diabetes rank ninth
among white men and women ages 35 to 64 in Appalachia
and eighth among elderly white men and women. For
black men of both age groups diabetes death rates
rank eighth. For black women diabetes death rates
rank seventh among ages 35 to 64 and fifth among
elderly black women. In general, high death rates
from diabetes are predominant in the central to
northern portions of the Appalachian region among
all demographic subgroups.
Suicide Mortality in Appalachia
The relatively small
numbers of suicides at the county-level is evident
in both the small value of the suicide rates as
well the narrow range of the values in each distribution.
Several high rate counties are coincident for ages
35 to 64 and 65 and older. These counties generally
appear in Eastern Virginia and along the West
Virginia border. Two high-outlier (unusually high
value) counties are apparent among persons ages
65 and older. These counties occur in Eastern Virginia
and Northeastern Alabama and
generally seem to mark the ends of a swath of high
rate counties that occur in the central to southern
portions of the region.
Infant Mortality in Appalachia
A
clear disparity in the level of infant mortality
rates between white and non-white populations is
made clear by examining the two distributions. Infant
mortality rates for the white population range from
1.6 to 17.1 deaths per 1,000 live births. In contrast,
infant mortality rates for non-white populations
range from 2.3 to 500.0 deaths per 1,000 live births.
II. Morbidity
Hospitalization data
provide the best available information on morbidity
for most health conditions. Inpatient hospitalizations
were obtained from the Health Care Cost and Utilization
Project (HCUP) database and the State Inpatient
Databases (SIDs) for the year 2000. Appalachian
states that are not participating are Ohio,
Mississippi, and Alabama.
Where the primary diagnosis for hospitalizations
was identified, these diagnoses included heart disease,
cancer(s), cerebrovascular disease (stroke), and
chronic obstructive pulmonary disease and allied
conditions (COPD), and diabetes.
Table 1. Number of hospitalizations by diagnosis
Diagnosis |
Number of
Hospitalizations |
Heart Disease |
338,012 |
COPD |
87,458 |
All Cancers |
85,083 |
Stroke |
75,835 |
Diabetes |
31,368 |
Other |
1,671,791 |
Total |
2,289,547 |
All-Cause Hospitalizations in Appalachia
High rates of hospitalization
are concentrated primarily in the Central Appalachian
counties in portions of Eastern Kentucky, Southern
West Virginia, and Western
Virginia for persons ages 35 to 64. High rates of
hospitalization are a bit more wide-spread for the
elderly.
Heart Disease Hospitalizations in Appalachia
Heart disease related
hospitalizations are responsible for approximately
15 percent of all hospitalizations in the year 2000
for the counties used in this analysis. High rates
of hospitalization are concentrated primarily in
the Central Appalachian counties in portions of
Eastern Kentucky, Southern West Virginia, and Western
Virginia for all population subgroups, although
there are concentrations in parts of Pennsylvania
and the southern tier of New
York, particularly for the elderly populations.
Cancer Hospitalizations in Appalachia
For this analysis, hospitalizations
with a primary diagnoses related to any malignant
neoplasms, cancers of various organs, and leukemia
were combined. High rates of cancer hospitalization
are fairly sporadic throughout the region, however
some general clusters of high rate counties occur
in Western Pennsylvania and in the Central Appalachian
counties in portions of Eastern Kentucky, Southern
West Virginia, and Western
Virginia for all population subgroups.
COPD Hospitalizations in Appalachia
Hospitalizations
with primary diagnoses related to chronic obstructive
pulmonary disease (COPD) include those resulting
from bronchitis, emphysema, and chronic airway obstruction
and does not include asthma. COPD related hospitalizations
are responsible for approximately 3.8 percent of
all hospitalizations in the year 2000 for the counties
used in this analysis. Major clustering occurring
in central Appalachia includes counties in Eastern
Kentucky, Southern West Virginia, and Western
Virginia. These clusters appear fairly consistently
among all population subgroups and most counties
designated as high outliers also appear in these
regions.
Diabetes Hospitalizations in Appalachia
Hospitalizations
with primary diagnoses related to diabetes include
those resulting from diabetes mellitus both Type
I and Type II. Diabetes related hospitalizations
are responsible for the fewest hospitalizations
among illnesses used in this analysis accounting
for approximately 1.4 percent of all hospitalizations
in the year 2000. Major clustering occurring in
central Appalachia including counties in Eastern
Kentucky, Southern West Virginia, and Western Virginia.
There is also a small group of counties in Eastern
Georgia with high diabetes hospitalization rates.
These clusters appear fairly consistently among
all population subgroups and most counties designated
as high outliers also appear in these regions.
III. Socioeconomic
Condition
There is a growing
awareness in the public health community that a
person's health (both physical and mental) is linked
to contextual circumstances and events in addition
to the influence of individual risks. Contextual
approaches examine the social and economic conditions
that affect all individuals who share a particular
environment: the social environment. The
variation in social landscapes in the U.S. and Appalachian
region reflects underlying differences in the contexts
in which regions and local areas have developed
and adapted to changes over time. Distinct geographic
variability in health outcomes suggests that contextual
differences across geographic space may influence
the overall health of regional and local populations.
In general, the
Appalachian region has lagged economically from
other parts of the U.S. Relatively high levels of
unemployment, low regional incomes, and educational
deficits continue to contribute to a lower standard
of living than enjoyed in many areas of the U.S.
However, there are significant levels of socioeconomic
diversity within Appalachia. For example, metropolitan areas
in the region have more diversified economies, higher
per capita incomes, and greater access to medical
care than non-metropolitan areas. Local socioeconomic
differences within the Appalachian region are likely
to be key contributors to disparities in health
outcomes with those areas having diminished access
to social, economic, and medical care resources
experiencing more adverse outcomes. However, direct
associations are also likely to vary throughout
the region.
The data and analyses
presented in this section are intended to reveal
potential associations between county-level
health outcomes and prevailing socioeconomic conditions.
We did not measure comprehensive associations, but
provide a basis from which to chart further work
relating socioeconomic conditions to health outcomes
in the region.
Unemployment
In 1990, the U.S.
average unemployment was 6.3%. In Appalachia
the average unemployment was 6.8%. County-level
unemployment rates ranged from 2.0% to 25.5% among
non-Appalachian U.S. counties and from
2.7% to 21.9% among counties within the Appalachian
region. Although the disparities in unemployment
rates among non-Appalachian counties in the U.S. had increased between
1990 and 2000, the disparities in unemployment among
Appalachian counties appear to have decreased. However
in both years, Appalachia had a higher proportion
of counties represented by higher rates of unemployment
than non-Appalachian U.S.
counties. In 1990 clusters of counties with high
rates of unemployment, relative to other counties
in the region, are evident primarily in Central
West Virginia, Southeastern Ohio, and Eastern
Kentucky. Despite an apparent decrease in unemployment
rates, as indicated by the distribution of values
for the year 2000, there appears to be a persistence
of relatively high unemployment among counties in
Central West Virginia, Southeastern Ohio, and Eastern
Kentucky.
Per Capita Income
Between 1990 and
2000 the distributions of per capita incomes among
Appalachian counties have become slightly more commensurate
with counties outside of Appalachia. However, Appalachian counties
continue to be more represented in the lower income
categories than non-Appalachian U.S.
counties. Concentrations of low per capita income
counties, relative to other Appalachian counties,
have persisted primarily in Eastern Kentucky and
Central and Southern West Virginia.
Median Family Income
>In 1990,
the median family income for non-Appalachian U.S. counties ranged
from $10,903 to $65,201. For Appalachian counties,
median family income range from $11,110 to $48,000
in 1990. In 2000 the median family income for non-Appalachian
U.S.
counties ranged from $14,167 to $97,225. For Appalachian
counties, median family income ranged from $18,034
to $74,003 in 2000.
Appalachian counties tend to be represented more
in the lower income ranges than in the higher ranges
compared with U.S. counties outside of Appalachia.
The geographic distribution of median family incomes
is very similar to the distribution of per capita
income, with lower incomes being represented by Central
Appalachian counties in Eastern Kentucky, and Central
and Southern West Virginia.
Percent Living Below Poverty Level
Poverty rates in
non-Appalachian U.S.
counties ranged from 0.0% to 63.1% in 1990. For
Appalachian counties, poverty rates ranged from
3.2% to 52.1% in 1990. In 2000, the range of poverty
rates decreased in both non-Appalachian counties
and Appalachian counties, ranging from 0.0% to 56.9%
and 5.2% to 45.4% respectively. Appalachian counties
tend to be more represented in the higher poverty
rate categories. The geographic distribution of poverty rates
is very similar to the distribution of per capita
income and median family income with higher poverty
rates being represented by Central Appalachian counties
in Eastern Kentucky, and Central and Southern
West Virginia. In general, it appears that high
rates of poverty are associated with highly rural
areas.
Educational Attainment
Dramatic differences
in educational attainment are evident among counties
in the U.S.
and Appalachia. In 1990, the
percent of persons with at least a high school diploma
in non-Appalachian U.S.
counties ranged from 31.6% to 95.5% and from 35.5%
to 87.2% for Appalachian counties. In the same year
the percentage of persons with a college degree
ranged from 3.7% to 53.4% among non-Appalachian
counties and from 3.7% to 41.7% among Appalachian
counties. By the year 2000, the ranges of values
for both indicators show significant improvement.
In 2000, the percentage of persons with at least
a high school diploma in non-Appalachian U.S.
counties ranged from 34.7% to 97.0% and from 49.2%
to 91.4% for Appalachian counties. The percentage
of persons with a college degree ranged from 4.9%
to 60.5% among non-Appalachian counties and from
5.6% to 47.6% among Appalachian counties.
Deficiencies in educational attainment are evident
in the Appalachian region when compared to the non-Appalachian
U.S. In 1990, Appalachian counties were more represented
in lower percentages with both high school diplomas
and college degrees when compared to non-Appalachian
U.S. counties. Despite improvements in educational
attainment for all U.S. counties by the year 2000,
the Appalachian region has, in general, continued
to lag behind much of the country. Low educational
attainment is prevalent in Central Appalachian counties
in Eastern Kentucky, Southern West Virginia, Eastern
Tennessee, and Western Virginia. These areas correspond
quite well to areas which are very rural, have high
levels of unemployment and low income levels.
IV. Behavioral
Risks
A number of specific
risk behaviors such as smoking, poor nutrition,
and lack of physical exercise are known to contribute
to the prevalence of a number of chronic diseases,
including cardiovascular and cerebrovascular disease
and cancer. It is believed that much of the burden
of chronic disease is preventable with modifications
of these risk behaviors. The prevalence of specific
risk behaviors may be influenced by socioeconomic
conditions of particular areas. Rural, underdeveloped
regions, for example, may have a poor public health
infrastructure, poor availability of healthy foods,
inadequate facilities for leisure-time physical
activity, and inadequate availability of medical
care and public health education resources.
Behavioral risk
data are drawn from the Behavioral Risk Factor Surveillance
System (BRFSS), which is based on a telephone survey
administered each year by state health departments
across the country. For this study, the following
risk factors were analyzed:
- Obesity (based on body mass index calculated
from self-reported weight and height)
- Cigarette smoking and smoking quit rates
- Physical inactivity
- Cancer screening (Mammography and rectal exams)
- Access to medical care (Insurance Coverage).
Obesity
With the exception of
black men, Appalachian counties tend to be more
represented among the higher obesity prevalence.
Cigarette smoking
Appalachian Labor Market Areas (LMAs) are more
represented in the higher ranges of smoking rates
compared with LMAs outside the Appalachian region.
LMAs with high rates of smoking appear to cluster
in the central Appalachian region for white men
and women, primarily in eastern Kentucky
and central and southern West Virginia. For black
men and women, there appears to be a north-south
gradient in smoking rates with higher rates occurring
in the more northern LMAs and lower rates in the
southern LMAs.
Physical Inactivity
Appalachian LMAs consistently are more represented
by the higher rates of physical inactivity compared
with LMAs outside of the region.
Cancer Screening
Appalachian LMAs generally are more represented
by the lower rates of mammography screening compared
with LMAs outside of the region. Appalachian LMAs
are also, for the most part, more represented by
the lower rates of colorectal cancer screening compared
with LMAs outside of the region
Health Insurance
In general it appears
that LMAs within Appalachia fair reasonably well when compared
to LMAs outside the region. However there also appear
to be groups of LMAs that are more represented among
the lowest rates of health care coverage. The lowest
rates of coverage occur consistently among white
men and women in eastern Kentucky. Low rates areas
appear in Western South Carolina for black men and
primarily in Southern Alabama and Eastern
Mississippi for black women.
V. Medical Care
Resources
Accessibility to adequate
medical care is a critical element of secondary
preventive efforts to reduce disease morbidity and
mortality. In much of rural Appalachia,
there are significant barriers to adequate medical
care including physical distance, terrain, lack
of public or private means of transportation to
providers, lack of health insurance, and inability
to pay for prescription drugs. In this report we
examine the geographic distribution of medical care
resources in order to help identify counties and
regions which have deficiencies in resources.
Health Professional Shortage Areas
Of the 406 Appalachian
counties used in this analysis, 108 counties have
health professional shortages throughout the county,
189 counties have shortages in part of the county,
and 109 counties have no shortages. Fairly large
regions, identified by clusters of counties that
have shortages for the whole county, are located
in Central West Virginia, Eastern Kentucky, Northeastern
Mississippi, and Central Alabama.
Hospitals
There were 81 counties in the region that had no
hospitals and 203 had a single hospital. Appalachian
counties with large metropolitan areas, such as Pittsburgh
and Birmingham have medical schools, teaching hospitals,
and are represented by large numbers of hospitals,
relative to other Appalachian counties.
Population Ratio per Hospital Bed
Population-to-hospital
bed ratios provide an indication of the overall
medical care resources available in a local area.
More favorable population-to-hospital bed ratios
are found in counties with metropolitan areas, but
are also found in non-metropolitan counties throughout
the region. No clear clustering of unfavorable population-to-hospital
bed ratios is apparent within the region.
Hospitals with Cardiac Intensive Care Units
(CICUs)
There were 296
counties in the region with no CICU, and fairly
large areas for which there are large distances
to the nearest CICU. More metropolitan areas within
the region, such as Pittsburgh,
Knoxville, and Birmingham
have comparatively large numbers of CICU hospitals.
Hospitals with Cardiac Catheterization Labs
and Rehabilitation Care
There were 318
counties that did not have hospitals with at least
one cardiac catheterization lab and 326 counties
that did not have at least one county with a cardiac
rehabilitation unit. Large areas within the region
do not have ready access to these critical services.
Counties with metropolitan areas have a greater
number of hospitals that offer these specialized
services.
Specialty Physicians
Favorable population-to-physician
ratios were found throughout the region. Counties
with less favorable ratios are found primarily in
Southeastern Ohio, Southern and Central West Virginia,
Eastern Kentucky, and North-Central
Mississippi. There were 6 Appalachian counties with
no physicians active in patient care in 1999. More
common physician specialties, such as cardiovascular
disease, emergency medicine, diagnostic radiology,
and pathology, are widely dispersed throughout the
region. However large areas within the region are
lacking these specialty medical services. There
appear to be a regional concentration, in Western
Pennsylvania, of physicians specializing in pulmonary
disease and physical rehabilitation. Physician specialties
that occur very sparsely among Appalachian counties
are colon and rectal surgery, general preventive
medicine, and public health.
Key Findings and
Challenges
This report
represents the first such analysis found in the
literature involving a regional review of mortality,
morbidity and risk and represents a new, fruitful
approach in disparities research. The central finding
of this report of pervasive disparities in premature
mortality in the region, as compared to the rest
of the nation, provides evidence for identifying
Appalachia as a geographic
health disparity population.
The findings
of this report indicate that the Appalachian Region
as a whole suffers considerable excess in mortality
from leading causes of death when compared to the
non-Appalachian U.S. Among the causes
of death examined in this study, Appalachian populations
suffer the most significant excesses in heart disease mortality, the leading cause of death in the U.S.
In addition, the Appalachian region suffers an excess
in premature deaths (among persons ages 35 to 64)
from heart disease, all cancers combined, lung cancer,
colorectal cancer, chronic obstructive pulmonary
disease, diabetes, and motor vehicle accidents,
relative to comparable non-Appalachian U.S. populations. As
this report has shown, there are considerable differences
in the burden of mortality among age/gender/ethnic
groups. The geographic patterns in national mortality
rates for different causes of death are often mirrored
in the Appalachian region, particularly by the apparent
north-south gradients for breast, colorectal and
lung cancer mortality, strokes, accidental deaths,
and diabetes.
There is a discernable
pattern of large clusters of high death rate counties
in Central Appalachia for multiple
causes of death. In many cases these concentrations
represent the largest such clusters in the country.
Among specific causes of death, which exhibit large
clusters of high death rate counties in the Appalachian
region, some of the most notable exist for heart
disease, all cancers, lung cancer, COPD, and diabetes.
Analysis of hospitalization
for different illnesses reveal similarities to the
geographic distribution to mortality rates, however
there is a high degree of within-region variability
in both the rates of mortality and hospitalization.
The lack of morbidity data hinders more extensive
analysis. Key morbidity data is lacking for individual
states in the nation and the region.
This
report finds higher percentages of obesity, smoking
and lack of physical activity in Appalachian labor
market areas compared with the U.S. These behaviors
are all considered risk factors to leading causes
of mortality. There appear to be some associations
among counties and clusters of counties with high
mortality/hospitalization rates and high prevalence
of behavioral risk factors.
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. However, the direct
role of socioeconomic conditions in influencing
health disparities is not clear. There are places
with adverse socioeconomic conditions that do not
endure the burden of adverse health outcomes relative
to other areas in the region.
Measures of
health service availability are generally crude
and limited in terms of measures of actual utilization
rates, access barriers, quality issues and cross-county
and cross-state utilization patterns. The available
data indicate an apparent centralization of specialty
health services in the region's metropolitan areas.
Policy Implications
The distributions
of excess mortality rates found in this report may
indicate a need for regional approaches to address
such health disparities, especially in the case
of excess premature deaths. In some cases, clusters
of counties with high death rates correspond to
clusters of counties with high risk factor prevalence.
In such cases, regional health prevention approaches
may make sense as an intervention strategy. The
clusters cross state boundaries and suggest that
interventions should be considered on a multi-state,
regional basis.
Deficiencies
in key morbidity data for every state suggest that
additional incentives ought to be considered to
encourage participation by all of the states in
the HCUP program and that a standardized data base
that guarantees both confidentiality and a robust
national research capability be developed for use
by public health researchers.
The effects
of the apparent centralization of specialized health
services in metropolitan areas on mortality and
morbidity rates in non-metro areas are not yet clear.
An alternative approach to measuring access to specialized
health services might be to identify services required
for a typical course of care by disease and to measure
relative access at multiple local levels.
It appears that
the reasons for disparities in health outcomes are
highly variable and localized. Additional research
is necessary to identify specific combinations of
factors that contribute to the health experience
of places within Appalachia.
The detailed findings of county-level health status
suggest that many health disparities are highly
localized in the region and result from a combination
of factors that are unique to each local area. Developing
targeted interventions, and local policies, to reduce
and eliminate health disparities in the region requires
an understanding of local conditions that influence
health outcomes.
In conjunction
with developing regional health policies, one of
the most significant challenges that is posed by
this type of study is addressing the key disparities
with local knowledge of conditions that exist in
these geographic areas. Although analysis of secondary
data sources is a critical part of developing an
understanding of the health conditions in Appalachia,
understanding the causes of disparities at the local
level often requires specific and detailed local
knowledge regarding events and conditions that influence
local health outcomes. Preliminary analyses suggest
a highly variable landscape of associations between
various health disparities and socioeconomic condition,
prevalence of behavioral risks, and access to available
medical care resources. Local responses and more
extensive analysis is required to identify how these
factors combine and intersect at the local level
to influence local health outcomes.
These findings
will be communicated to each of the states included
in the Appalachian Regional Commission's area. The
Commission should consider promoting regional collaborations
among states and partnerships with other Federal
agencies to address the disparities identified in
this report.
|