Place Matters: Health Disparities in the Commonwealth

Place Matters: Health Disparities in the Commonwealth A Report on the Delta and Appalachian Regions of Kentucky Sarah Walsh, MPH, CHES W. Jay Christian, MPH Claudia Hopenhayn, PhD, MPH A project of the Foundation for a Healthy Kentucky and the University of Kentucky College of Public Health

Place Matters: Health Disparities in the Commonwealth The Foundation for a Healthy Kentucky is a non-profit, philanthropic organization working to address the unmet health care needs of Kentuckians. Our approach centers on developing and influencing health policy, to promote lasting change in the systems by which health care is provided and good health sustained, to: improve access to care, reduce health risks and disparities, and promote health equity. The Foundation makes grants, supports research, holds educational forums and convenes communities to engage and develop the capacity of the Commonwealth to improve the health and quality of life of all Kentuckians. For more information about the Foundation and its mission, please visit www.healthy-ky.org. The University of Kentucky is a public, land-grant university dedicated to improving people s lives through excellence in education, research and creative work, service, and health care. As Kentucky s flagship institution, the University plays a critical leadership role by promoting diversity, inclusion, economic development and human well-being. As a component of Kentucky s land grant institution, the mission of the College of Public Health at the University of Kentucky is to apply comprehensive health approaches to understand better and to help reduce the burdens and disparities of health problems on individuals, families and communities. For more information about the University and its mission, please visit www.uky.edu. Suggested citation: Walsh SE, Christian WJ, Hopenhayn C. Place Matters: Health Disparities in the Commonwealth, A Report on the Delta and Appalachian Regions of Kentucky. Louisville, KY: Foundation for a Healthy Kentucky, 2012. This project was funded by a grant from the Foundation for a Healthy Kentucky 2

A Report on the Delta and Appalachian Regions of Kentucky one Commonwealth, blessed with diversity excerpt from the pledge of allegiance to the flag of the Commonwealth of Kentucky 3

Place Matters: Health Disparities in the Commonwealth Table of Contents Introduction...5 About the Delta Region...7 About the Appalachian Region...7 Regional Comparisons...8 Overall Health...9 Access to Care...11 Preventive Services...12 Health Behaviors...13 Chronic Disease...14 Trends in the Delta Region...16 Overall Health...17 Access to Care...18 Preventive Services...19 Health Behaviors...20 Chronic Disease...20 Trends in the Appalachian Region...22 Overall Health...23 Access to Care...25 Preventive Services...26 Health Behaviors...26 Chronic Disease...28 Data Tables...30 References...34 Acknowledgements...35 4

A Report on the Delta and Appalachian Regions of Kentucky Place Matters: Health Disparities in the Commonwealth A Report on the Delta and Appalachian Regions of Kentucky One of the overarching goals of Healthy People 2020 is to achieve health equity, eliminate disparities, and improve the health of all groups. 1 Echoing this goal, the first ever National Prevention Strategy identified four strategic directions to improve health and wellbeing in the United States, including the elimination of health disparities. 2 In adopting this strategic direction, the National Prevention Council stated All Americans should have the opportunity to live long, healthy, independent, and productive lives, regardless of their race or ethnicity; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics. (National Prevention Strategy, p. 11) We believe that health disparities can be eliminated, and that they must be eliminated. The first step towards eliminating health disparities is to understand and monitor where they exist. By harnessing the power of health information, we can inform policymakers, community leaders and concerned citizens about health disparities in our state. We hope that this data will contribute to the conversation about health in our communities, and fuel efforts to change. About this Report This report, Place Matters, is the first in a series of reports exploring health disparities in the Commonwealth using data from the Kentucky Behavioral Risk Factor Surveillance System (BRFSS). Place Matters focuses on geographic disparities, and differences in health status for different regions of the state. Future reports will analyze disparities related to race, gender, income, education, and other demographic characteristics of Kentuckians. Nationally, BRFSS is a joint effort of the Centers for Disease Control and Prevention (CDC) and the participating states and territories. It is the world s largest telephone health survey, and has been used to track information on risk behaviors, prevention practices and access to care since 1984. understanding, the Cabinet for Health and Family Services makes data from the Kentucky BRFSS available to the University of Kentucky and to the Foundation for a Healthy Kentucky for this research. We are grateful to the Kentucky BRFSS program, without which this analysis would not be possible. Place Matters describes the health and health behaviors of adults in two regions of the state: the Delta counties of western Kentucky and the Appalachian counties of eastern Kentucky. The Delta counties are part of a culturally-rich region along the Mississippi, Ohio, Cumberland and Tennessee rivers. The Delta region in Kentucky claims the natural beauty of the Land Between the Lakes, world famous quilt making, successful farming communities and busy health care hubs but historically, it is also an economically distressed region. Similarly, the Appalachian counties carry the proud heritage of Daniel Boone, country music, and stunning natural resources but again, the region also experiences devastating levels of poverty. For both their strengths and their challenges, the health of the Delta and Appalachian regions warrant a closer look. This report is presented in three sections. The first section describes the current state of health disparities, comparing current BRFSS data for the Delta and Appalachian regions with the state as a whole. The second section describes historic trends in the Delta region, and changes over time from 2003 to 2010. The third section looks at trends in the Appalachian region for this same time period. Delta and Appalachian Regions of Kentucky Delta Region Appalachian Region Central Kentucky Each year, the Kentucky BRFSS gathers input from nearly 11,000 Kentucky adults. As part of a memorandum of 5

Place Matters: Health Disparities in the Commonwealth Understanding the Data Each graph in this report presents an estimate and a confidence interval. The estimate represents the proportion of respondents who gave a particular answer when they were contacted by the Kentucky Behavioral Risk Factor Surveillance System (BRFSS). The confidence interval tells us what the responses would have been if we had contacted every adult in the region, instead of just a sample. We can be 95% confident that if we had contacted everyone, the true proportion of all respondents who would have given that answer would fall within that confidence interval. The more people we talk to, the better our estimate. For this reason, the confidence intervals for statelevel estimates tend to be narrower than for either the Delta or Appalachian regions, where the sample size is smaller. For example, 25.2% of the Kentucky adults contacted by Kentucky BRFSS were smokers in 2008-2010. If we had contacted everyone, we would expect that between 24.2% and 26.2% of adults would be smokers. For this question, the 95% confidence interval ranges from 24.2% to 26.2%. Why does this matter? When two confidence intervals overlap, say the smoking rates for the Delta region and the state as a whole, we cannot know for certain if the differences in responses are a result of real differences in the communities, or if those differences are a function of who happened to answer the phone when Kentucky BRFSS called. But when the confidence intervals don t overlap, we know that in 95 out of 100 cases the differences we have measured between communities would be real no matter how many adults we surveyed. It is important to understand where these real differences or disparities exist, so that we can work together to address the differences and promote health throughout the Commonwealth. Key Findings for the Delta Region In general, responses from Delta region adults were comparable to the state as a whole. Although the results were not significantly different from the state, there were a few key differences in the Delta region which warrant further attention. Compared to the state as a whole, adults in the Delta region were: less likely to have an individual they think of as their personal doctor or health care provider. more likely to have ever been tested for HIV. more likely to report binge drinking in the past month. less likely to be overweight or obese. Over time, several important trends have emerged in the Delta region some positive, some negative. Between 2003 and 2010, the proportion of Delta region adults who: went without needed medical care due to the cost decreased. did not receive an annual flu vaccination decreased. reported binge drinking in the past month increased. were current smokers decreased. were obese increased. Key Findings for the Appalachian Region Results in the Appalachian region were often markedly different from the state as a whole, and there were a number of significant differences in the Appalachian region. Compared to the state as a whole, adults in the Appalachian region were: more likely to describe their health as fair or poor. more likely to go without needed medical care due to the cost. less likely to have health insurance. more likely to have asthma. As with the Delta region, a number of important trends have emerged over time. Between 2003 and 2010, the proportion of Appalachian region adults who: did not receive an annual flu vaccination decreased. reported binge drinking in the past month increased. were current smokers decreased. were obese increased. had diabetes increased. 6

Delta Region The Delta Regional Authority (www.dra.gov) was established by Congress in 2000 to enhance economic development and improve quality of life in the 252 Delta counties and parishes. The Delta region Meade is comprised of portions of 8 Hancock Henderson Breckinridge states, including 22 counties Union Daviess Webster McLean in western Kentucky. Ohio Grayson Ballard Caldwell Calloway Carlisle Appalachian Region The Appalachian Regional Commission (www.arc.gov) was established by Congress in 1965 to be a strategic partner and advocate for sustainable community and economic development in Appalachia. The Appalachian region includes 420 counties in 13 states, including 54 counties in eastern Kentucky. Kenton Boone Campbell Gallatin Bracken Carroll Pendleton Mason Trimble Grant Owen Robertson Lewis Greenup Oldham Henry Harrison Nicholas Fleming Carter Boyd Jefferson Shelby FranklinScott Bourbon Bath Rowan Elliott Spencer Woodford Lawrence Anderson Fayette Bullitt Clark Montgomery Jessamine Menifee Morgan Nelson Mercer Powell Johnson Washington Madison Wolfe Martin Hardin Garrard Estill Magoffin Boyle Lee Marion Floyd LaRue Breathitt Lincoln Jackson Pike Owsley Crittenden Taylor Rockcastle Knott Livingston Hopkins Hart Casey Perry Butler Green Muhlenberg Edmonson Caldwell Clay Adair Pulaski Laurel Letcher Leslie Ballard McCracken Lyon Christian Warren Barren Metcalfe Russell Logan Knox Carlisle Marshall Trigg Todd Wayne Cumberland Harlan Graves Whitley Simpson Allen Hickman Monroe Clinton McCreary Bell Calloway Fulton Christian Crittenden Daviess Fulton Graves Henderson Hickman Hopkins Livingston Lyon Marshall McCracken Approximately a half million people live in the Delta Region of Kentucky. 3 Adair Bath Bell Boyd Breathitt Carter Casey Clark Clay McLean Muhlenberg Todd Trigg Boone Kenton Campbell Gallatin Bracken Pendleton Carroll Grant Trimble Mason Owen Robertson Lewis Oldham Henry Greenup Harrison Nicholas Fleming Carter Boyd Jefferson Shelby FranklinScott Bourbon Bath Rowan Elliott Spencer Woodford Montgomery Meade Bullitt Anderson Fayette Lawrence Clark Hancock Menifee Morgan Nelson Jessamine Johnson Breckinridge Mercer Henderson Washington Wolfe Martin Union Daviess Madison Hardin Garrard Estill Magoffin Boyle Lee Webster McLean LaRue Marion Floyd Breathitt Ohio Grayson Lincoln Pike JacksonOwsley Crittenden Taylor Rockcastle Knott Livingston Hopkins Hart Casey Perry Muhlenberg Butler Green Edmonson Caldwell Clay Adair Pulaski Laurel Letcher Leslie Ballard McCracken Lyon Warren Christian Barren Metcalfe Russell Carlisle Marshall Logan Knox Trigg Todd Cumberland Wayne Whitley Harlan Graves Simpson Allen Hickman Monroe Clinton McCreary Bell Calloway Fulton Clinton Cumberland Edmonson Elliott Estill Fleming Floyd Garrard Green Greenup Harlan Hart Jackson Johnson Knott Knox Laurel Lawrence Lee Leslie Letcher Lewis Lincoln Madison Magoffin Martin McCreary Nearly 1.2 million people live in the Appalachian region of Kentucky. 4 A Report on the Delta and Appalachian Regions of Kentucky Menifee Metcalfe Monroe Montgomery Morgan Nicholas Owsley Perry Pike Union Webster Powell Pulaski Robertson Rockcastle Rowan Russell Wayne Whitley Wolfe For the purposes of this report, the Appalachian region is defined by the service area of the Appalachian Regional Commission (ARC). However, it should be noted that the boundaries of the ARC have changed somewhat over time. For example, Metcalfe, Nicholas, and Robertson counties were added to the ARC region in 2008. For ease of comparisons, the current geographic boundaries of Kentucky s Appalachian region (i.e. the 54 Kentucky counties currently served by the ARC) have been used for all time periods covered in this report. 7

Place Matters: Health Disparities in the Commonwealth Regional Comparisons 8

A Report on the Delta and Appalachian Regions of Kentucky Regional Comparisons In this section, we review data from 2008-2010 time period, for both the Delta and Appalachian regions of Kentucky. For comparison, these data are presented with responses from the state as a whole. Information for other time periods, and data for the central Kentucky counties which are not a part of either the Delta or the Appalachian regions are included in the data tables at the end of this report. Overall Health Fair or Poor Health BRFSS asks respondents to rate their overall health status as excellent, very good, good, fair or poor. This graph illustrates the proportion of adults who describe their health as something less than good. About 1 in 5 adults (21.5%) in Kentucky describe their overall health as fair or poor. This is similar to the proportion of adults in the Delta region (21.9%) who describe their health as fair or poor. Adults living in the Appalachian region are significantly more likely to describe their health as fair or poor, with nearly 3 in 10 (29.6%) reporting less than good health. Overall, Kentuckians experience poorer health status than the national average. Throughout the United States, just 1 in 7 adults (14.6%) 5 describe their health as fair or poor. Fair or Poor Health Status 2008-2010 32% Poor Mental Health For this question, respondents are asked thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good? The graph below presents the proportion of adults who indicated their mental health was not good on 14 or more days in the preceding month. For the state as a whole, about 1 in 7 adults (14.4%) experienced poor mental health for more than 2 weeks out of the month. The rate of poor mental health was similar in the Delta region (13.5%), but significantly higher in the Appalachian region (17.6%). Poor Mental Health 2008-2010 10% 8% 6% 4% 2% 0% 13.5% Delta 17.6% Appalachia 14.4% Kentucky 30% 28% 29.6% 21.9% 21.5% Delta Appalachia Kentucky 9

Place Matters: Health Disparities in the Commonwealth Poor Physical Health This question is similar to the question about mental health, but in this case, respondents were asked how many days their physical health, which includes physical illness and injury was not good. The graph presents the portion of adults who indicated their physical health was not good on 14 or more days during the preceding month. More than 1 in 5 Appalachian adults (20.8%) reported that their physical health was not good for at least two weeks out of the month. This is significantly higher than the state average (15.8%). The number of Delta region (15.7%) adults in poor physical health is similar to the state average. Activity Limitations Poor Physical Health 2008-2010 Activity Limitations 2008-2010 10% 8% 6% 15.7% Delta 20.8% Appalachia 15.8% Kentucky Poor physical and mental health can have a profound impact on our quality of life, and being unhealthy makes it difficult to do the things we need and want to do. About 1 in 4 Kentucky adults (25.1%) reported that their physical or mental health had kept them from doing their usual activities, such as self-care, work, or recreation. Similarly, 1 in 4 adults in the Delta region (24.6%) reported that their health status limited their activities on one or more days in the preceding month. Adults in the Appalachian region were significantly more likely to report that their health impacted their quality of life, with nearly 1 in 3 (31.0%) reporting that their physical or mental health status had limited their activities in the preceding month. 34% 32% 30% 28% 24.6% Delta 31% Appalachia 25.1% Kentucky 10

A Report on the Delta and Appalachian Regions of Kentucky Access to Care Foregoing Medical Care Due to Cost About 1 in 6 Kentucky (16.9%) adults reported that there was a time in the past year when they needed to see a doctor but could not, because of the cost. It is difficult to get and stay healthy if you cannot get care when you need it, yet a sizable number of Kentuckians are foregoing care due to the expense. Adults living in the Delta region are slightly less likely to report going without needed medical services (14.8%), but this difference is not statistically significant. Access to care is considerably more limited in the Appalachian region of Kentucky, with nearly 1 in 4 adults (22.9%) unable to afford needed medical care. Considerable work needs to be done to make health care more affordable for all people. One of the objectives of Healthy People 2020 is to have fewer than 1 in 20 (4.2%) 6 people forego needed medical care due to the cost. Foregoing Medical Care Due to Cost 2008-2010 14.8% 22.9% 16.9% No Personal Doctor More than 1 in 6 adults in the Delta region (18.1%) and the Appalachian region (17.5%) do not have an individual that they think of as their personal doctor or health care provider. In both cases, this is higher than the state average (15.8%). While this difference is not statistically significant, it suggests that adults in the Delta and Appalachian regions are less likely to have a usual source of health care than elsewhere in the state. A personal health care provider can help to coordinate an individual s care and improve continuity of services throughout the health care system. No Personal Doctor 2008-2010 10% 8% 6% 18.1% 17.5% Delta Appalachia 15.8% Kentucky 10% 8% 6% Delta Appalachia Kentucky 11

Place Matters: Health Disparities in the Commonwealth No Health Insurance Coverage An important factor in obtaining needed health services is having medical coverage to help pay for those services, yet many Kentucky adults lack health insurance. About 1 in 7 adults in the Delta region (14.4%) lacks health insurance coverage, similar to the state average (15.7%). Adults in the Appalachian region are significantly more likely to go without health insurance. About 1 in 5 Appalachian adults (20.2%) is uninsured. While virtually all Kentuckians over age 65 (99%) have some form of health insurance 7, coverage varies considerably for younger adults (ages 18-64). Among those ages 18-64, about 1 in 10 Kentucky adults (9.7%) are covered by Medicaid 8. No Health Insurance Coverage 2008-2010 10% 8% 6% 14.4% Delta 20.2% Appalachia Preventive Services No Seasonal Flu Vaccination 15.7% Kentucky An annual vaccine is the best way to prevent seasonal influenza, yet the majority of Kentucky adults (59.7%) do not receive annual flu shots 9. In the Appalachian region, more than 6 in 10 adults (63.8%) did not receive a flu shot in the past year. This is significantly higher than the state average. The rate in the Delta region is similar to the state average, with slightly less than 6 in 10 (59.4%) going without an annual flu shot. No Seasonal Flu Vaccination 2008-2010 70% 68% 66% 64% 62% 60% 58% 56% 54% 52% 50% Delta Ever Tested for HIV Only respondents younger than 65 are asked about HIV screening on the BRFSS survey. Of those younger than 65, adults in the Delta region are more likely to report having ever been tested for HIV, the virus that causes AIDS. Fewer than 4 in 10 Delta region adults (38.0%) have ever been screened for HIV. Just 1 in 3 adults in the Appalachian region (33.3%) has ever been screened for HIV. Neither region is significantly different than the state average (36.2%). The CDC recommends that routine HIV screening be provided to everyone, as part of their routine health care, unless they decline to be tested (this is called opt-out screening). 10 Ever Tested for HIV 2008-2010 46% 44% 42% 40% 38% 36% 34% 32% 30% 59.4% 38% 63.8% Appalachia 33.3% 59.7% Kentucky 36.2% 28% Delta Appalachia Kentucky 12

A Report on the Delta and Appalachian Regions of Kentucky Health Behaviors Binge Drinking Binge drinking is defined as consuming five or more alcoholic beverages on one occasion for men, or consuming four or more alcoholic beverages on one occasion for women. Consuming large amounts of alcohol in a short period of time can impair judgment and increase risk of injuries, in addition to other health consequences. Fewer than 1 in 8 Kentucky adults (11.9%) had engaged in binge drinking in the month prior to the survey. The rate of binge drinking is slightly higher in the Delta region (13.5%), although this difference is not statistically significant. Adults in the Appalachian region are significantly less likely to drink heavily, with only about 1 in 12 (8.8%) having engaged in binge drinking in the past 30 days. Overall, binge drinking is one of the health status indicators where Kentucky fares best in comparison to national averages. Nationwide, more than 1 in 7 adults (15.5%) reports binge drinking in the previous month. 11 Binge Drinking 2008-2010 10% 13.5% 11.9% Current Smokers Smoking increases the risk of cancer, heart disease, stroke and other chronic conditions, and reduces overall health status. 12 In Kentucky, about 1 in 4 adults (25.2%) is a current smoker, and a similar proportion of adults in the Delta region (24.6%) smoke regularly. The prevalence of smoking is significantly higher in the Appalachian region, where nearly 3 in 10 adults (29.4%) is a current smoker. Kentucky has considerable work to do in order to achieve the Healthy People 2020 objective of having fewer than 1 in 8 adults (12.0%) be current smokers. 13 Current Smokers 2008-2010 34% 32% 30% 28% 24.6% Delta 29.4% Appalachia 25.2% Kentucky 8% 6% 8.8% 4% 2% 0% Delta Appalachia Kentucky 13

Place Matters: Health Disparities in the Commonwealth No Physical Activity At minimum, adults should get 30 minutes of moderate physical activity on at least 5 days per week. 14 Despite this recommendation, about 3 in 10 Kentucky adults (29.8%) engaged in no leisure time physical activity or exercise in the past month. Similarly, 3 in 10 adults (29.6%) in the Delta region did not participate in any physical activity in the past month. Adults in Appalachia were less likely to get any physical activity, with more than 1 in 3 (35.6%) reporting that they did not participate in any exercise in the past month. No Physcial Activity 2008-2010 Obesity 2008-2010 40% 38% 36% 34% 32% 30% 28% 30.2% 34.6% 31.5% 40% 38% 36% 34% 32% 30% 28% Chronic Disease Obesity 29.6% Delta 35.6% Appalachia 29.8% Kentucky For adults, obesity is defined as having a Body Mass Index 15 of 30.0 or higher. Obesity is both a chronic disease itself and a risk factor for other diseases, including heart disease, stroke, type 2 diabetes and certain cancers. More than 3 in 10 Kentucky adults (31.5%) and Delta region adults (30.2%) are obese. The prevalence of obesity is even higher in the Appalachian region, where more than 1 in 3 adults (34.6%) is obese. Delta Overweight Overweight is defined as having a Body Mass Index of 25.0 or higher, and this category includes those who are obese (those with a Body Mass Index greater than 30.0). Like obesity, being overweight increases an individual s risk of other chronic diseases. In Kentucky, the majority of adults weigh more than they should. Specifically, 2 in 3 Kentucky adults (67.1%) are overweight. The prevalence of overweight is slightly lower in the Delta region (65.5%), but this difference is not statistically significant. However, the prevalence of overweight is significantly higher in the Appalachian region, with 7 in 10 adults (70.1%) weighing more than they should. Overweight 2008-2010 76% 74% 72% 70% 68% 66% 64% 62% 65.5% Appalachia 70.1% Kentucky 67.1% 60% 58% 56% Delta Appalachia Kentucky 14

A Report on the Delta and Appalachian Regions of Kentucky Asthma More than 1 in 7 adults in the Delta region (15.0%) have ever been told by a doctor, nurse, or other health professional that they have asthma. The prevalence of asthma in the Delta region is similar to the state average. Asthma is slightly more common in the Appalachian region, where more than 1 in 6 adults (17.0%) have been told they have asthma. Nationally, about 1 in 8 adults (13.5%) has asthma. 16 Asthma 2008-2010 10% 15% 17% 14.8% Diabetes About 1 in 10 Kentucky adults (10.5%) have at some point been told by a doctor, nurse, or other health professional that they have diabetes. This estimate includes individuals with both Type 1 and Type 2 diabetes, but does not include women who experienced gestational diabetes during pregnancy. The prevalence of diabetes in the Delta region (10.4%) is similar to the state average. Diabetes is slightly more common in Appalachia, where more than 1 in 8 adults (13.3%) have been told they have diabetes. Diabetes prevalence exceeds the national average (8.4%) 17 in all regions of the state. Diabetes 2008-2010 8% 6% 4% 10% 8% 10.4% 13.3% 10.5% 2% 6% 0% Delta Appalachia Kentucky 4% 2% 0% Delta Appalachia Kentucky 15

Place Matters: Health Disparities in the Commonwealth Trends in the Delta Region 16

Pennsylvania A Report on the Delta and Appalachian Regions of Kentucky Trends in the Delta Region Missouri Arkansas Louisiana Illinois Mississippi Kentucky Tennessee Alabama Poor Mental Health Despite the potential improvements in overall health status, reported mental health has remained relatively level in the Delta region. In 2003-2005, about 1 in 7 adults (14.9%) experienced poor mental health status on 14 or more days during the preceding month. Six years later, the rate of poor mental health is virtually unchanged in the region. Poor Mental Health Delta Region 14.9% 14.7% 12.3% 12.3% 12.4% 13.5% In the preceding section, the Delta region and the Appalachian region were compared to the state average to identify health disparities in a single time period. In this section, we will explore how health and health behavior have changed in the Delta region over time. Trend data for the state as a whole are included in the data tables at the end of this report. Fair or Poor Health Status Delta Region 30% 28% Overall Health Fair or Poor Health Since the 2005-2007 time period, the proportion of Delta region adults who would describe their overall health status as fair or poor has decreased from roughly 1 in 4 (24.6%) to just over 1 in 5 (21.9%). While this decrease has not yet achieved statistical significance, it is suggestive of a promising trend for the region. 10% 8% 6% Poor Physical Health While the proportion of Delta region adults reporting poor physical health on 14 or more days during the preceding month appears to have inched up slightly, this has not changed significantly over time. Poor Physical Health Delta Region 10% 8% 14.8% 15% 15.3% 15.9% 15.7% 23.7% 24.3% 24.6% 22.9% 22.4% 21.9% 17

Place Matters: Health Disparities in the Commonwealth Activity Limitations In 2008-2010, approximately 1 in 4 Delta region adults (24.6%) reported that poor physical or mental health kept them from their usual activities at least once during the preceding month. This figure has remained steady throughout the study period. Activity Limitations Delta Region 30% 28% 23% 24.6% 24.5% 24.5% 23.5% 24.6% Foregoing Medical Care Due to Cost Delta Region Access to Care Foregoing Medical Care Due to Cost In 2008-2010, about 1 in 7 Delta region adults (14.8%) reported that they had gone without needed medical care at some point during the past year due to the cost. This is a statistically significant reduction in the proportion of adults foregoing care in the region, and suggests that adults in this region are better able to afford needed medical services, or have more low cost care options, than in the past. No Personal Doctor Since 2004-2006, fewer adults are reporting that they lack a personal doctor or health care provider in the Delta region. While this trend is not yet statistically significant, it suggests that adults in the region are more likely to have a medical home and continuity of care than in previous years. No Personal Doctor Delta Region 20.6% 22.2% 20.8% 19.4% No Health Insurance Coverage No Health Insurance Coverage Delta Region 18.2% 18.1% In 2008-2010, about 1 in 7 adults in the Delta region (14.4%) lacked health insurance coverage. While the trend is not yet statistically significant, fewer people seem to be uninsured today than in previous years. As previously noted, nearly all Kentuckians over age 65 (99%) have some form of health insurance 18, but coverage varies considerably for younger adults (ages 18-64). Among those ages 18-64, about 1 in 12 Delta region adults (8.7%) are covered by Medicaid 19. 18.7% 17.6% 17.4% 15.4% 16.2% 14.8% 17% 17.4% 17.7% 15.7% 14.6% 14.4% 10% 10% 18

A Report on the Delta and Appalachian Regions of Kentucky Preventive Services No Seasonal Flu Vaccination While there is work to be done, significant progress has been made with regards to flu prevention in the Delta region. The proportion of adults who did not receive a seasonal flu shot in the past year decreased from nearly 7 in 10 (69.1%) in 2004-2006 to fewer than 6 in 10 (59.4%) in 2008-2010. No Seasonal Flu Vaccination Delta Region Ever Tested for HIV In 2008-2010, fewer than 4 in 10 adults in the Delta region (38.0%) reported having ever been tested for HIV, the virus that causes AIDS. This question is only asked of respondents younger than 65 years old. The portion of adults who have been tested for HIV did not change significantly during the analyzed time periods. Ever Tested for HIV Delta Region 70% 68.2% 69.1% 68% 66% 64% 66.2% 63% 40% 38% 36% 34% 37.6% 34.8% 33.6% 33.5% 37.3% 38% 62% 32% 60% 60.3% 59.4% 30% 58% 28% 19

Place Matters: Health Disparities in the Commonwealth Binge Drinking Delta Region 10% Health Behaviors Binge Drinking Binge drinking is defined as consuming five or more alcoholic beverages on one occasion for men, or consuming four or more alcoholic beverages on one occasion for women. More than 1 in 8 adults in the Delta region (13.5%) reported binge drinking in the 30 days prior to the BRFSS survey, in 2008-2010. This represents a significant increase in binge drinking over previous years. 8% 6% 9.3% Current Smokers Current Smokers Delta Region 8.5% 8.6% 9.3% 11.9% 13.5% During the study period, considerable progress has been made towards reducing the rate of smoking in the Delta region. In 2008-2010, about 1 in 4 adults (24.6%) in the Delta region was a current smoker. This is a significant decrease from previous years. No Physical Activity Physical inactivity appears to be declining in the Delta region, although this change is not yet statistically significant. About 3 in 10 adults (29.6%) in the Delta region report that they engaged in no leisure time physical activity during the preceding month. No Physical Activity Delta Region 36% 34% 32% 30% 28% 31.2% 31.7% 31.5% 30.5% 28.7% 29.6% Obesity Delta Region 36% 34% Chronic Disease Obesity The prevalence of obesity that is, having a Body Mass Index of 30 or higher - continues to increase in the Delta region. More than 3 in 10 Delta region adults (30.3%) are obese, and this represents a statistically significant increase since the beginning of the study. 32% 30% 28% 29.9% 29.7% 29.8% 27.2% 24.6% 32% 30.3% 30% 29.6% 29.7% 29.7% 28.8% 28% 26.4% 20

A Report on the Delta and Appalachian Regions of Kentucky Overweight Diabetes Individuals are considered overweight if they have a Body Mass Index greater than 25. This category includes those who would be classified as obese, that is, individuals with a Body Mass Index greater than 30. Taken together, 2 out of 3 adults in the Delta region (65.5%) weigh more than they should. The proportion of overweight adults appears to be increasing, however, this change is not statistically significant for the time periods included in this study. Overweight or Obese Delta Region 72% 70% 68% 66% 64% 62% 63.7% 64.7% About 1 in 10 adults (10.4%) in the Delta region have been diagnosed with diabetes. The prevalence of diabetes has increased slightly over time, but this change is not statistically significant. Diabetes Delta Region 10% 8% 6% 8.7% 9% 9.9% 9.7% 10.5% 10.4% 66.5% 66.9% 67% 4% 65.5% 60% Asthma More than 1 in 7 adults (15.0%) in the Delta region have been diagnosed with asthma. As with other chronic diseases, the proportion of adults in the Delta region who have ever been told they have asthma appears to be increasing over time. However, this trend is not statistically significant. Asthma Delta Region 13% 12.8% 12.2% 12.1% 13.5% 15% 10% 8% 6% 21

Place Matters: Health Disparities in the Commonwealth Trends in the Appalachian Region 22

A Report on the Delta and Appalachian Regions of Kentucky Trends in the Appalachian Region New York Pennsylvania Ohio Maryland West Virginia Virginia Kentucky North Carolina Tennessee South Carolina Poor Mental Health Despite the potential improvements in overall health status, mental health has remained relatively flat in the Appalachian region. In 2008-2010, more than 1 in 6 adults (17.6%) experienced poor mental health status on 14 or more days during the preceding month. This is virtually unchanged from the rate observed six years prior. Poor Mental Health Appalachian Region In the preceding section, the Delta region and the Appalachian region were compared to the state average to identify health disparities in a single time period. In this section, we will explore how health and health behavior have changed in the Appalachian region over time. Trend data for the state as a whole are included in the data tables at the end of this report. Fair or Poor Health Status Appalachian Region 36% Mississippi Alabama Overall Health Fair or Poor Health Georgia The proportion of adults in the Appalachian region who describe their health as fair or poor appears to be decreasing over time. While this trend is not yet statistically significant, it suggests a positive change in the region, as roughly 3 in 10 adults in Appalachia (29.6%) are in less than good health. 18.3% 18.3% 17.9% 18.2% 18.1% 17.6% 34% 32% 30% 28% 32.1% 31.3% 31.6% 30.3% 30.7% 29.6% 23

Place Matters: Health Disparities in the Commonwealth Poor Physical Health As with mental health, the proportion of Appalachian region adults experiencing poor physical health has remained steady throughout the study period. About 1 in 5 adults (20.8%) in this region experiences poor physical health on 14 or more days per month. Poor Physical Health Appalachian Region Activity Limitations In 2008-2010, approximately 3 in 10 Appalachian region adults (31.0%) reported that poor physical or mental health kept them from their usual activities at least once during the preceding month. This figure has not changed significantly during the study period. Activity Limitations Appalachian Region 36% 20.4% 20.7% 21.2% 20.5% 20.5% 20.8% 34% 32% 30% 29.9% 30.8% 31.6% 31.8% 30.6% 31% 28% 24

Foregoing Medical Care Due to Cost Appalachian Region 28% Access to Care Foregoing Medical Care Due to Cost In 2008-2010, more than 1 in 5 Appalachian region adults (22.9%) reported that they had gone without needed medical year at some point during the past year due to the cost. The ability to afford needed medical services is an ongoing challenge for this region. A Report on the Delta and Appalachian Regions of Kentucky 23.5% 23.4% 23.3% 22.7% 22.6% 22.9% No Personal Doctor In 2008-2010, more than 1 in 6 adults (17.5%) in the Appalachian region reported that there was not one person they thought of as their personal doctor or health care provider. The proportion of Appalachian adults with no personal doctor has remained fairly steady throughout the study period. This suggests that many adults in the region are unlikely to have a medical home or continuity of care. No Personal Doctor Appalachian Region 18.7% 19.1% 18.6% 17.6% 17.3% 17.5% No Health Insurance Coverage In 2008-2010, about 1 in 5 adults in the Appalachian region (20.2%) lacked health insurance coverage. While the trend is not yet statistically significant, fewer people seem to be uninsured today than in previous years. As previously noted, nearly all Kentuckians over age 65 (99%) have some form of health insurance 20, but coverage varies considerably for younger adults (ages 18-64). Among those ages 18-64, about 1 in 6 Appalachian region adults (16.8%) are covered by Medicaid 21. No Health Insurance Coverage Appalachian Region 22.6% 22.4% 22.9% 21.4% 20.7% 20.2% 25

Place Matters: Health Disparities in the Commonwealth Preventive Services No Seasonal Flu Vaccination While there is work to be done, significant progress has been made with regards to flu prevention in the Appalachian region. The proportion of adults who did not receive a seasonal flu shot in the past year decreased from nearly 3 in 4 (73.5%) in 2004-2006 to less than 2 in 3 (63.8%) in 2008-2010. No Seasonal Flu Vaccination Appalachian Region 74% 72.7% 73.5% Ever Tested for HIV In 2008-2010, just 1 in 3 adults in the Appalachian region (33.3%) reported having ever been tested for HIV, the virus that causes AIDS. This question is only asked of respondents younger than 65 years old. The portion of adults who have been tested for HIV appeared to be increasing during the analyzed time periods. The 2008-2010 estimate is significantly higher than earlier years, though it is not statistically different than the earliest period in the study (2003-2005). Ever Tested for HIV Appalachian Region 38% 72% 71.3% 36% 70% 68% 66% 64% 67.9% 65.3% 63.8% 34% 32% 30% 28% 30.5% 28.2% 27.5% 29% 31.7% 33.3% 62% 26

A Report on the Delta and Appalachian Regions of Kentucky Binge Drinking Appalachian Region 10% Health Behaviors Binge Drinking Binge drinking is defined as consuming five or more alcoholic beverages on one occasion for men, or consuming four or more alcoholic beverages on one occasion for women. More than 1 in 12 adults in the Appalachian region (8.8%) reported binge drinking in the 30 days prior to the BRFSS survey, in 2008-2010. While the Appalachian region continues to have lower rates of binge drinking than the state as a whole, this represents a significant increase since 2003-2005. 8% 6% 6.3% 6.8% 6.9% 7.6% 8.5% 8.8% Current Smokers During the study period, considerable progress has been made towards reducing the rate of smoking in the Appalachian region. In 2008-2010, about 3 in 10 adults (29.4%) in the Appalachian region were current smokers. This is a significant decrease from previous years. Current Smokers Appalachian Region 36% 34% 32% 30% 28% 32.4% 31.5% 32.1% 31% 30.3% 29.4% 4% 2% 27

Place Matters: Health Disparities in the Commonwealth No Physical Activity Physical inactivity appears to be declining in the Appalachian region, although this change is not yet statistically significant. More than 1 in 3 adults (35.6%) in the Appalachian region continue to report that they engaged in no leisure time physical activity during the preceding month. No Physical Activity Appalachian Region 42% 40% 38% 36% 34% 32% 30% 37.5% 37.4% 38.3% 36.8% 37.2% 35.6% Obesity Appalachian Region 36% 34% 32% 30% 28% Chronic Disease Obesity The prevalence of obesity that is, having a Body Mass Index of 30 or higher - has increased steadily and significantly in the Appalachian region. More than 1 in 3 Appalachian region adults (34.6%) are obese, and this represents a statistically significant increase since the beginning of the study.. 28.9% 30.4% 32.6% 33.4% 34% 34.6% 28

A Report on the Delta and Appalachian Regions of Kentucky Overweight Individuals are considered overweight if they have a Body Mass Index greater than 25. This category includes those who would be classified as obese, that is, individuals with a Body Mass Index greater than 30. Taken together, 7 in 10 adults in the Appalachian region (70.1%) weigh more than they should. As was observed with the prevalence of obesity, the rate of overweight in the Appalachian region has increased significantly over time. Overweight or Obese Appalachian Region 72% 70% 68% 66% 65.6% 66.4% 67.8% 69.8% 70.4% 70.1% Diabetes About 1 in 8 adults (13.8%) in the Appalachian region have been diagnosed with diabetes. The prevalence of diabetes has increased significantly in this region over time. Diabetes Appalachian Region 10% 8% 6% 4% 9.9% 10.4% 11% 12.7% 13.3% 64% 62% 60% Asthma More than 1 in 6 adults (17.0%) in the Appalachian region have been diagnosed with asthma. As with other chronic diseases, the proportion of adults in the Appalachian region who have ever been told they have asthma appears to be increasing over time and this trend is approaching statistically significance. Asthma Appalachian Region 10% 15% 14.6% 14.8% 15.1% 16.1% 17% 8% 29

Place Matters: Health Disparities in the Commonwealth Data Tables Delta Region Appalachian Region Central Kentucky Kentucky Overall Health Fair or Poor Health Status 2003-2005 23.69% (22.03-25.44) 32.08% (30.73-33.46) 17.90% (16.82-19.03) 22.81% (22.03-23.61) 2004-2006 24.25% (22.41-26.19) 31.32% (29.92-32.76) 18. (17.15-19.42) 22.93% (22.12-23.75) 2005-2007 24.56% (22.60-26.62) 31.63% (30.21-33.08) 18.61% (17.51-19.76) 23.31% (22.50-24.14) 2006-2008 22.94% (21.13-24.86) 30.30% (28.93-31.70) 17.75% (16.70-18.86) 22. (21.38-22.96) 2007-2009 22.39% (20.68-24.19) 30.72% (29.39-32.09) 17.70% (16.66-18.79) 22.05% (21.29-22.83) 2008-2010 21.90% (20.30-23.58) 29.63% (28.35-30.93) 17.56% (16.51-18.67) 21.53% (20.78-22.31) Poor Mental Health ( 14 days per month) 2003-2005 14.86% (13.48-16.34) 18.25% (17.09-19.46) 12.59% (11.61-13.65) 14.54% (13.84-15.26) 2004-2006 14.69% (13.25-16.27) 18.33% (17.10-19.62) 12.49% (11.49-13.57) 14.50% (13.79-15.25) 2005-2007 12.28% (10.96-13.74) 17.91% (16.71-19.18) 11.98% (10.98-13.06) 13.77% (13.07-14.51) 2006-2008 12.27% (10.93-13.76) 18. (16.96-19.46) 11.59% (10.58-12.70) 13.62% (12.90-14.37) 2007-2009 12.40% (11.03-13.91) 18.05% (16.89-19.27) 12.21% (11.15-13.35) 13.89% (13.16-14.66) 2008-2010 13.54% (12.11-15.11) 17.60% (16.47-18.78) 13.09% (12.01-14.24) 14.41% (13.68-15.18) Poor Physical Health ( 14 days per month) 2003-2005 14.84% (13.47-16.32) 20.40% (19.23-21.63) 11.65% (10.72-12.66) 14.61% (13.93-15.31) 2004-2006 15.03% (13.55-16.64) 20.73% (19.49-22.02) 12.37% (11.41-13.40) 15.17% (14.48-15.90) 2005-2007 15.34% (13.82-17.00) 21.19% (19.95-22.48) 12.78% (11.83-13.78) 15.62% (14.93-16.34) 2006-2008 15.86% (14.34-17.51) 21.50% (20.30-22.75) 12.84% (11.93-13.81) 15.79% (15.12-16.49) 2007-2009 15.96% (14.48-17.55) 21.50% (20.36-22.69) 13.15% (12.20-14.16) 15.89% (15.21-16.60) 2008-2010 15.68% (14.30-17.17) 20.75% (19.64-21.90) 13.43% (12.46-14.45) 15.78% (15.10-16.48) Activities Limited Due to Health 2003-2005 22.97% (21.33-24.69) 29.94% (28.60-31.32) 19.96% (18.78-21.19) 23.27% (22.45-24.11) 2004-2006 24.63% (22.75-26.61) 30.81% (29.36-32.30) 20.81% (19.60-22.08) 24.28% (23.42-25.17) 2005-2007 24.49% (22.54-26.54) 31.63% (30.16-33.13) 20.99% (19.81-22.22) 24.64% (23.78-25.51) 2006-2008 24.54% (22.63-26.57) 31.83% (30.40-33.30) 22.63% (21.38-23.93) 25.60% (24.72-26.50) 2007-2009 23.53% (21.80-25.35) 30.55% (29.23-31.90) 21.98% (20.75-23.26) 24.64% (23.79-25.51) 2008-2010 24.59% (22.93-26.34) 31.03% (29.71-32.37) 22.37% (21.13-23.66) 25. (24.27-25.98) 30

A Report on the Delta and Appalachian Regions of Kentucky Delta Region Appalachian Region Central Kentucky Kentucky Access to Care Foregoing Medical Care Due to Cost 2003-2005 18.65% (16.96-20.47) 23.54% (22.23-24.91) 14.57% (13.45-15.78) 17.75% (16.95-18.57) 2004-2006 17.57% (15.76-19.53) 23.37% (21.97-24.84) 14.75% (13.57-16.01) 17.67% (16.84-18.54) 2005-2007 17.43% (15.56-19.49) 23.30% (21.88-24.78) 14.51% (13.36-15.75) 17.54% (16.71-18.40) 2006-2008 15.39% (13.71-17.25) 22.74% (21.37-24.18) 13.94% (12.80-15.16) 16.74% (15.93-17.59) 2007-2009 16.23% (14.55-18.06) 22.55% (21.25-23.90) 14.31% (13.18-15.52) 16.92% (16.13-17.75) 2008-2010 14.80% (13.21-16.54) 22.88% (21.51-24.32) 14.43% (13.28-15.67) 16.86% (16.04-17.71) No Personal Doctor 2003-2005 20.62% (18.72-22.66) 18.66% (17.43-19.97) 16.48% (15.19-17.85) 17.70% (16.83-18.60) 2004-2006 22. (19.87-24.63) 19.09% (17.73-20.53) 16. (14.87-17.62) 17.89% (16.97-18.85) 2005-2007 20.81% (18.38-23.46) 18.59% (17.12-20.16) 15.08% (13.79-16.46) 16.91% (15.98-17.87) 2006-2008 19.41% (17.08-21.98) 17.63% (16.13-19.23) 14.40% (13.15-15.75) 16.02% (15.11-16.98 2007-2009 18. (16.19-20.49) 17.30% (15.85-18.86) 13.01% (11.83-14.29) 14.93% (14.07-15.84) 2008-2010 18.13% (16.20-20.23) 17.53% (16.09-19.07) 14.39% (13.12-15.76) 15.78% (14.88-16.72) No Health Insurance Coverage 2003-2005 17.00% (15.28-18.87) 22.55% (21.21-23.96) 13.39% (12.25-14.62) 16.55% (15.74-17.40) 2004-2006 17.36% (15.29-19.64) 22.41% (20.95-23.95) 13.25% (12.07-14.52) 16.51% (15.65-17.41) 2005-2007 17.73% (15.50-20.22) 22.89% (21.34-24.51) 13.41% (12.20-14.72) 16.82% (15.93-17.76) 2006-2008 15.65% (13.57-17.98) 21.38% (19.91-22.93) 12.86% (11.64-14.18) 15.75% (14.87-16.68) 2007-2009 14.57% (12.77-16.57) 20.72% (19.35-22.16) 12.82% (11.62-14.12) 15.31% (14.46-16.20) 2008-2010 14.44% (12.73-16.34) 20. (18.91-21.63) 13.72% (12.50-15.03) 15.65% (14.80-16.53) Preventive Services No Seasonal Flu Vaccination 2003-2005 68.15% (66.27-69.97) 72.70% (71.35-74.00) 68.81% (67.35-70.23) 69.84% (68.89-70.77) 2004-2006 69.11% (67.04-71.11) 73.46% (72.01-74.86) 68. (66.61-69.59) 69.82% (68.83-70.79) 2005-2007 66. (63.91-68.41) 71.31% (69.83-72.74) 66.27% (64.75-67.74) 67.76% (66.75-68.75) 2006-2008 62.95% (60.67-65.18) 67.85% (66.31-69.35) 61.17% (59.62-62.71) 63.39% (62.35-64.42) 2007-2009 60.29% (58.10-62.45) 65.31% (63.85-66.75) 59. (57.62-60.68) 61.09% (60.06-62.10) 2008-2010 59.38% (57.31-61.42) 63.81% (62.33-65.27) 57.71% (56.13-59.26) 59.67% (58.63-60.70) 31

Place Matters: Health Disparities in the Commonwealth Delta Region Appalachian Region Central Kentucky Kentucky Preventive Services (Continued) Ever Tested for HIV 2003-2005 37.61% (35.20-40.08) 30.53% (28.83-32.27) 38.62% (36.76-40.51) 36. (34.93-37.41) 2004-2006 34.79% (32.12-37.56) 28. (26.45-30.06) 36.57% (34.65-38.53) 33.87% (32.59-35.17) 2005-2007 33.59% (30.70-36.62) 27.46% (25.71-29.27) 34.09% (32.21-36.03) 32.03% (30.77-33.32) 2006-2008 33.50% (30.64-36.48) 29.04% (27.27-30.88) 35.04% (33.17-36.97) 33.04% (31.78-34.33) 2007-2009 37.32% (34.53-40.20) 31.70% (29.97-33.48) 35.79% (33.96-37.68) 34.81% (33.57-36.07) 2008-2010 37.96% (35.36-40.63) 33.27% (31.48-35.12) 37.15% (35.30-39.05) 36.15% (34.90-37.43) Health Behaviors Binge Drinking in the Past Month 2003-2005 9.25% (7.86-10.84) 6.33% (5.52-7.25) 11.66% (10.50-12.92) 9.77% (9.03-10.56) 2004-2006 8.54% (7.14-10.18) 6.75% (5.81-7.84) 11.27% (10.13-12.53) 9.56% (8.81-10.36) 2005-2007 8.58% (7.04-10.40) 6.90% (5.89-8.06) 10.30% (9.26-11.45) 9.05% (8.35-9.81) 2006-2008 9.32% (7.79-11.10) 7.63% (6.57-8.84) 10.31% (9.26-11.48) 9.39% (8.66-10.17) 2007-2009 11.89% (10.09-13.97) 8.53% (7.47-9.72) 11.40% (10.28-12.62) 10.64% (9.87-11.46) 2008-2010 13.53% (11.74-15.54) 8.81% (7.77-9.97) 12.99% (11.78-14.30) 11.87% (11.06-12.73) Current Smokers 2003-2005 29.94% (27.96-31.99) 32.41% (30.97-33.88) 26.98% (25.53-28.49) 28.97% (28.00-29.96) 2004-2006 29.73% (27.57-31.99) 31.49% (29.95-33.08) 26.19% (24.74-27.70) 28.25% (27.25-29.26) 2005-2007 29.83% (27.52-32.24) 32.05% (30.46-33.68) 26. (24.81-27.71) 28.46% (27.46-29.48) 2006-2008 27. (25.00-29.48) 30.96% (29.37-32.60) 25.43% (23.99-26.93) 27.30% (26.30-28.33) 2007-2009 25.99% (23.88-28.22) 30.25% (28.75-31.79) 24.47% (23.02-25.97) 26.33% (25.34-27.34) 2008-2010 24.61% (22.66-26.68) 29.38% (27.89-30.91) 23.34% (21.92-24.84) 25.21% (24.24-26.22) No Physical Activity in the Past Month 2003-2005 31. (29.42-33.11) 37.52% (36.06-39.00) 27.05% (25.69-28.45) 30.67% (29.74-31.61) 2004-2006 31.71% (29.56-33.93) 37.37% (35.82-38.94) 26.80% (25.42-28.22) 30.59% (29.63-31.57) 2005-2007 31.46% (29.18-33.84) 38.31% (36.74-39.91) 26.56% (25.22-27.94) 30.74% (29.79-31.71) 2006-2008 30.45% (28.20-32.79) 36.84% (35.30-38.40) 27.02% (25.70-28.39) 30.39% (29.45-31.35) 2007-2009 28.66% (26.73-30.66) 37.23% (35.75-38.74) 26.99% (25.68-28.33) 30. (29.23-31.07) 2008-2010 29.56% (27.72-31.46) 35.56% (34.13-37.01) 27. (25.80-28.47) 29.82% (28.90-30.74) 32

A Report on the Delta and Appalachian Regions of Kentucky Delta Region Appalachian Region Central Kentucky Kentucky Chronic Disease Prevalence of Obesity 2003-2005 26.36% (24.58-28.23) 28.86% (27.48-30.29) 25.69% (24.26-27.17) 26.70% (25.75-27.66) 2004-2006 28.81% (26.64-31.09) 30.42% (28.92-31.95) 25.64% (24.21-27.14) 27.49% (26.50-28.49) 2005-2007 29.64% (27.28-32.11) 32.57% (31.00-34.17) 26.00% (24.60-27.45) 28.45% (27.46-29.45) 2006-2008 29.70% (27.39-32.13) 33.43% (31.88-35.02) 26.57% (25.18-28.01) 29.02% (28.04-30.02) 2007-2009 29.67% (27.60-31.84) 33.97% (32.48-35.48) 28.91% (27.49-30.38) 30.47% (29349-31.46) 2008-2010 30.32% (28.38-32.34) 34.58% (33.13-36.06) 30.25% (28.78-31.76) 31.48% (30.49-32.49) Prevalence of Overweight (including obese) 2003-2005 63.67% (61.57-65.72) 65.54% (63.95-67.08) 62.94% (61.31-64.53) 63.79% (62.72-64.85) 2004-2006 64.69% (62.38-66.93) 66.42% (64.74-68.06) 64. (62.50-65.78) 64.89% (63.79-65.98) 2005-2007 66.47% (64.07-68.79) 68.78% (67.17-70.34) 65.83% (64.25-67.38) 66.79% (65.73-67.84) 2006-2008 66.85% (64.48-69.14) 69.82% (68.22-71.37) 66.31% (64.73-67.86) 67.42% (66.36-68.47) 2007-2009 67.03% (64.79-69.20) 70.35% (68.83-71.82) 66.43% (64.88-67.95) 67.64% (66.60-68.66) 2008-2010 65.50% (63.31-67.63) 70.08% (68.53-71.58) 66.06% (64.46-67.62) 67. (66.05-68.16) Prevalence of Asthma 2003-2005 13.00% (11.51-14.66) 14.96% (13.88-16.11) 12.48% (11.44-13.61) 13.27% (12.56-14.02) 2004-2006 12.84% (11.23-14.64) 14.61% (13.51-15.78) 12.17% (11.14-13.29) 12.98% (12.26-13.73) 2005-2007 12.15% (10.57-13.94) 14.84% (13.72-16.04) 11.42% (10.44-12.49) 12.54% (11.85-13.27) 2006-2008 12. (10.60-13.84) 15.11% (14.01-16.27) 12.13% (11.11-13.23) 13.01% (12.30-13.75) 2007-2009 13.47% (11.89-15.24) 16. (15.01-17.30) 13. (12.11-14.33) 14.06% (13.32-14.84) 2008-2010 14.99% (13.34-16.81) 16.95% (15.87-18.09) 13.76% (12.69-14.92) 14.83% (14.08-15.60) Prevalence of Diabetes 2003-2005 8.66% (7.69-9.74) 9.90% (9.10-10.77) 7.41% (6.72-8.17) 8.31% (7.83-8.82) 2004-2006 9.00% (7.88-10.27) 10.41% (9.57-11.31) 7.87% (7.15-8.66) 8.78% (8.27-9.31) 2005-2007 9.89% (8.66-11.27) 10.99% (10.16-11.88) 8.74% (7.98-9.56) 9.57% (9.04-10.13) 2006-2008 9.66% (8.48-10.99) 11.98% (11.16-12.86) 8.85% (8.12-9.63) 9.89% (9.37-10.42) 2007-2009 10.45% (9.31-11.70) 12.73% (11.90-13.60) 9.28% (8.56-10.06) 10.42% (9.91-10.96) 2008-2010 10.44% (9.37-11.62) 13.25% (12.43-14.11) 9. (8.43-9.90) 10.47% (9.97-11.00) 33

Place Matters: Health Disparities in the Commonwealth References 1 U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Healthy People 2020. Washington, DC. Available at http://www.healthypeople. gov/2020/about/disparitiesabout.aspx. Accessed July 20, 2012. 2 National Prevention Council. National Prevention Strategy. Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General, 2011. Available at http://www.healthcare.gov/prevention/nphpphc/strategy/report. pdf. Accessed August 15, 2012. 3 In 2011, an estimated 500,440 Kentuckians lived in the 21 Delta region counties, 11.5% of all Kentucky residents. Source: U.S. Census Bureau, Population Division. Annual estimates of the resident population for Kentucky, ADDs, and Counties: April 1, 2010 to July 1, 2011. Available at http://ksdc.louisville. edu. Accessed July 30, 2012. 4 In 2011, an estimated 1,186,135 Kentuckians lived in the 54 Appalachian region counties, 27.1% of all Kentucky residents. Source: U.S. Census Bureau, Population Division. Annual estimates of the resident population for Kentucky, ADDs, and Counties: April 1, 2010 to July 1, 2011. Available at http://ksdc. louisville.edu. Accessed July 30, 2012. 5 2009 BRFSS nationwide estimate for the 50 states, District of Columbia, Guam, Puerto Rico and the U.S. Virgin Islands. Source: Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2009. Available at http://apps.nccd.cdc.gov/brfss/. Accessed August 10, 2012. 6 U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Healthy People 2020. Washington, DC. Available at http://www.healthypeople. gov/2020/about/disparitiesabout.aspx. Accessed July 20, 2012. 7 U.S. Census Bureau. 2010 American Community Survey 1-Year Estimates: Health Insurance Coverage Status By Sex By Age. Available at http://factfinder2.census.gov/. Accessed August 24, 2012. 8 In 2010, 265,978 Kentucky adults ages 18-64 were enrolled in Medicaid. Source: Department for Medicaid Services, Division of Administration and Financial Management. MS-264 Part A Supplement: Characteristics of Eligible MS Recipients, By County, July 2010. Frankfort, KY: Cabinet for Health and Family Services. Available at http://chfs.ky.gov/dms/stats.htm. Accessed August 24, 2012. 9 Seasonal flu vaccinations are available as a shot or nasal spray. Estimates provided in this report are for the proportion of adults who have received an annual flu shot only, because the data for nasal spray utilization is not available for all time periods in this report. It should be noted that nasal spray utilization in Kentucky is very low and would not change the estimates very much. 10 Branson BM, Handsfield HH, Lampe, MA, Janssen RS, Taylor AW, Lyss SB and JE Clark. Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings. MMWR 55(RR14);1-17, September 22, 2006. Available at http://www.cdc.gov/mmwr/preview/ mmwrhtml/rr5514a1.htm. Accessed August 9, 2012. 11 2009 BRFSS nationwide estimate for the 50 states, District of Columbia, Guam, Puerto Rico and the U.S. Virgin Islands. Source: Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2009. Available at http://apps.nccd.cdc.gov/brfss/. Accessed August 10, 2012. 12 U.S. Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office of Smoking and Health, 2004. Available at http://www.cdc.gov/ tobacco/data_statistics/sgr/2004/index.htm. Accessed August 9, 2012. 13 U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Healthy People 2020. Washington, DC. Available at http://www.healthypeople. gov/2020/about/disparitiesabout.aspx. Accessed July 20, 2012. 14 U.S. Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Available at http://www.health.gov/ paguidelines/guidelines/default.aspx. Accessed August 9, 2012. 15 Body Mass Index, or BMI, is equal to weight in pounds divided by height in inches squared and then multiplied by 703. For a 5 9 individual, a BMI of 30.0 would correspond to a weight of 203 lbs. 16 2009 BRFSS nationwide estimate for the 50 states, District of Columbia, Guam, Puerto Rico and the U.S. Virgin Islands. Source: Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2009. Available at http://apps.nccd.cdc.gov/brfss/. Accessed August 10, 2012. 17 2009 BRFSS nationwide estimate for the 50 states, District of Columbia, Guam, Puerto Rico and the U.S. Virgin Islands. Source: Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2009. Available at http://apps.nccd.cdc.gov/brfss/. Accessed August 10, 2012. 18 U.S. Census Bureau. 2010 American Community Survey 1-Year Estimates: Health Insurance Coverage Status By Sex By Age. Available at http://factfinder2.census.gov/. Accessed August 24, 2012. 19 In 2010, 26,758 Delta region adults ages 18-64 were enrolled in Medicaid. Source: Department for Medicaid Services, Division of Administration and Financial Management. MS-264 Part A Supplement: Characteristics of Eligible MS Recipients, By County, July 2010. Frankfort, KY: Cabinet for Health and Family Services. Available at http://chfs.ky.gov/dms/stats.htm. Accessed August 24, 2012. 20 U.S. Census Bureau. 2010 American Community Survey 1-Year Estimates: Health Insurance Coverage Status By Sex By Age. Available at http://factfinder2.census.gov/. Accessed August 24, 2012. 21 In 2010, 124,805 Appalachian region adults ages 18-64 were enrolled in Medicaid. Source: Department for Medicaid Services, Division of Administration and Financial Management. MS-264 Part A Supplement: Characteristics of Eligible MS Recipients, By County, July 2010. Frankfort, KY: Cabinet for Health and Family Services. Available at http:// chfs.ky.gov/dms/stats.htm. Accessed August 24, 2012. 34

A Report on the Delta and Appalachian Regions of Kentucky Acknowledgements The authors are grateful to the following individuals for their assistance in developing this report: M. Gabriela Alcalde, MPH, DrPH Amy Christian, MSPH Rob Gorstein Design Sarojini Kanotra, PhD, MPH Seth Siameh, MPH Susan Zepeda, PhD 35

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