Disparities and Bright Spots HEALTH DISPARITIES IN APPALACHIA The first report in a series exploring health issues in Appalachia 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. August 2017 CREATING A CULTURE OF Acknowledgments | HEALTH DISPARITIES HEALTH IN APPALACHIA 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. i CREATING A CULTURE OF Acknowledgments | HEALTH DISPARITIES HEALTH IN APPALACHIA 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 Pam Silberman, JD, DrPH, Associate Director and Research, Appalachian Regional for Policy Analysis, UNC Cecil G. Commission Sheps Center for Health Research Logan Thomas, MA, Division of Planning and William Holding, MHA, Senior Consultant Research, Appalachian Regional and Data Analyst, PDA, Inc. Commission Lisa Villamil, MAE, Assistant Professor, Nancy M. Lane, MA, President, PDA, Inc. UNC Chapel Hill School of Media and Journalism G.Mark Holmes, PhD, Center Director, UNC Cecil G. Sheps Center for Health Sharita Thomas, MPP, Research Associate Research Cecil G. Sheps Center at the University of North Carolina at Thomas A. Arcury, PhD, Program Director, Chapel Hill Wake Forest Baptist Medical Center Clinical and Translational Science Maura Lane, BA, communications and Institute marketing executive Randy Randolph, MRP, Applications Analyst Janine Latus, MA, writer and speaker Programmer, UNC Cecil G. Sheps Center for Health Research 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 Amy Martin, DrPh, MSPH, College of Reproductive Health, Centers for Dental Medicine, Medical Disease Control and Prevention University of South Carolina Rozelia Harris, MBA, Director of Wayne Myers, MD Mississippi Office of Rural Health and Primary Care, Mississippi State Kadie Peters, Vice President of Community Department of Health 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. ii CREATING A CULTURE OF Table of Contents | HEALTH DISPARITIES HEALTH IN APPALACHIA 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 iii CREATING A CULTURE OF Table of Contents | HEALTH DISPARITIES HEALTH IN APPALACHIA 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 iv CREATING A CULTURE OF Table of Contents | HEALTH DISPARITIES HEALTH IN APPALACHIA 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 v CREATING A CULTURE OF Table of Contents | HEALTH DISPARITIES HEALTH IN APPALACHIA 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 vi CREATING A CULTURE OF Glossary | HEALTH DISPARITIES HEALTH IN APPALACHIA GLOSSARY OF TERMS Area Health The Area Health Resources Files (AHRF) are a family of health data Resources Files 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 The Appalachian Regional Commission (ARC) is a regional economic Regional development agency that represents a partnership of federal, state, and local Commission 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 ARC uses an index-based classification system to compare each county in the Index 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 The ACS is an ongoing survey conducted by the U.S. Census Bureau. This Community Survey survey samples the population on a number of topics including population, (ACS) age, education, home ownership, income, labor force, migration, and veteran status. Behavioral Risk The Behavioral Risk Factor Surveillance System (BRFSS) is the nation's Factor Surveillance premier system of health-related telephone surveys that collects state-level System 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 The Centers for Disease Control and Prevention (CDC) is the leading national Control and public health protection agency in the United States. The CDC administers a Prevention 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. vii CREATING A CULTURE OF Glossary | HEALTH DISPARITIES HEALTH IN APPALACHIA County Health The County Health Rankings & Roadmaps program is a collaboration between Rankings 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. Population- Rather than simply averaging values across counties, weighted averages Weighted Average 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. viii