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1.  Overcoming Data Challenges Examining Oral Health Disparities in Appalachia 
Online Journal of Public Health Informatics  2012;4(3):ojphi.v4i3.4279.
Objective
The objective of our study of oral health disparities in Appalachia was to use existing data sources to geographically analyze suspected disparities in oral health status in the 420 counties of Appalachia, and to make sub-state comparisons within Appalachia and to the rest of the nation. The purpose of this manuscript is to describe the methods used to overcome challenges associated with using limited oral health data to make inferences about oral health status.
Methods:
Oral health data were obtained from the Behavioral Risk Factor Surveillance System (BRFSS). Because the BRFSS was designed for state-level analysis, there were inadequate numbers of responses to study Appalachia by county. We set out to determine the smallest possible unit we could use, aggregating data to satisfy CDC minimum requirements for spatially identified responses. For sub-state comparisons, data were first aggregated to Appalachian and non-Appalachian regions within Appalachian states. Next, urban versus rural areas within Appalachian and non-Appalachian regions were examined. Beale codes were used to define metropolitan and non-metropolitan statistical regions for the United States.
Results:
Aggregating the data as described proved useful for smoothing the data used to analyze oral health disparities, while still revealing important sub-state differences. Using geographic information systems to map data throughout the process was very useful for determining an effective approach for our analysis.
Discussion:
Studying oral health disparities on a regional or national level is difficult given a lack of appropriate data. The BRFSS can be adapted for this purpose; however, there is a limited number of oral health questions and because they are also optional, they are not routinely asked by all states. Expanding the BRFSS to include a larger sampling frame would be very helpful for studying oral health disparities.
Conclusions:
Novel techniques were introduced to use BRFSS data to study oral health disparities in Appalachia, which provided informative sub-state results, useful to health planners for targeting intervention strategies.
doi:10.5210/ojphi.v4i3.4279
PMCID: PMC3615824  PMID: 23569642
Behavioral Risk Factor Surveillance System (BRFSS); Beale codes; oral health; disparities; Geographic Information Systems (GIS)
2.  Clustering Tooth Surfaces into Biologically Informative Caries Outcomes 
Journal of Dental Research  2013;92(1):32-37.
Dental caries affects most adults worldwide; however, the risk factors for dental caries do not necessarily exert their effects uniformly across all tooth surfaces. Instead, the actions of some risk factors may be limited to a subset of teeth/surfaces. Therefore, we used hierarchical clustering on tooth surface-level caries data for 1,068 Appalachian adults (ages 18-75 yrs) to group surfaces based on co-occurrence of caries. Our cluster analysis yielded evidence of 5 distinct groups of tooth surfaces that differ with respect to caries: (C1) pit and fissure molar surfaces, (C2) mandibular anterior surfaces, (C3) posterior non-pit and fissure surfaces, (C4) maxillary anterior surfaces, and (C5) mid-dentition surfaces. These clusters were replicated in a national dataset (NHANES 1999-2000, N = 3,123). We created new caries outcomes defined as the number of carious tooth surfaces within each cluster. We show that some cluster-based caries outcomes are heritable (i.e., under genetic regulation; p < 0.05), whereas others are not. Likewise, we demonstrate the association between some cluster-based caries outcomes and potential risk factors such as age, sex, educational attainment, and toothbrushing habits. Together, these results suggest that the permanent dentition can be subdivided into groups of tooth surfaces that are useful for understanding the factors influencing cariogenesis. Abbreviations: COHRA, Center for Oral Health in Appalachia, the principal study sample; C1-5, clusters 1-5, groups of similarly behaving tooth surfaces identified through hierarchical clustering; DMFS index, decayed, missing, or filled surfaces, a traditional caries measure representing the number of affected surfaces across the entire dentition; DMFS1-5, partial DMFS indices representing the number of affected surfaces within a hierarchical cluster; and NHANES, National Health and Nutrition Examination Survey, the secondary study sample.
doi:10.1177/0022034512463241
PMCID: PMC3521447  PMID: 23064960
dental caries; permanent dentition; white spots; hierarchical clustering; cluster analysis; heritability
3.  Oral cancer screening and dental care use among women from Ohio Appalachia 
Rural and remote health  2012;12:2184.
Introduction
Residents of Appalachia may benefit from oral cancer screening given the region’s higher oral and pharyngeal cancer mortality rates. The current study examined the oral cancer screening behaviors and recent dental care (since dentists perform most screening examinations) of women from Ohio Appalachia.
Methods
Women from Ohio Appalachia were surveyed for the Community Awareness Resources Education (CARE) study, which was completed in 2006. A secondary aim of the CARE baseline survey was to examine oral cancer screening and dental care use among women from this region. Outcomes included whether women (n=477; cooperation rate = 71%) had ever had an oral cancer screening examination and when their most recent dental visit had occurred. Various demographic characteristics, health behaviors and psychosocial factors were examined as potential correlates. Analyses used multivariate logistic regression.
Results
Most women identified tobacco-related products as risk factors for oral cancer, but 43% of women did not know an early sign of oral cancer. Only 15% of women reported ever having had an oral cancer screening examination, with approximately 80% of these women indicating that a dentist had performed their most recent examination. Women were less likely to have reported a previous examination if they were from urban areas (OR=0.33, 95% CI: 0.13–0.85) or perceived a lower locus of health control (OR=0.94, 95% CI: 0.89–0.98). Women were more likely to have reported a previous examination if they had had a dental visit within the last year (OR=2.24, 95% CI: 1.03–4.88). Only 65% of women, however, indicated a dental visit within the last year. Women were more likely to have reported a recent dental visit if they were of a high socioeconomic status (OR=2.83, 95% CI: 1.58–5.06), had private health insurance (OR=2.20, 95% CI: 1.21–3.97) or had consumed alcohol in the last month (OR=2.03, 95% CI: 1.20–3.42).
Conclusion
Oral cancer screening was not common among women from Ohio Appalachia, with many missed opportunities having occurred at dental visits. Education programs targeting dentists and other healthcare providers (given dental providers are lacking in some areas of Ohio Appalachia) about opportunistic oral cancer screening may help to improve screening in Appalachia. These programs should include information about populations at high risk for oral cancer (eg smokers) and how screening may be especially beneficial for them. Future research is needed to examine the acceptability of such education programs to healthcare providers in the Appalachian region and to explore why screening was less common among women living in urban areas of Ohio Appalachia.
PMCID: PMC3838993  PMID: 23240899
Appalachia; oral cancer; screening; USA
4.  Social and Cultural Factors Influencing Health in Southern West Virginia: A Qualitative Study 
Preventing Chronic Disease  2006;3(4):A124.
Introduction
Social, cultural, and economic environments are associated with high rates of disease incidence and mortality in poor Appalachian regions of the United States. Although many historical studies suggest that aspects of Appalachian culture (e.g., fatalism, patriarchy) include values and beliefs that may put Appalachians at risk for poor health, other cultural aspects may be protective (e.g., strong social ties). Few recent studies have explored regional cultural issues qualitatively. The purpose of this study was to examine social and cultural factors that may be associated with health and illness in an Appalachian region.
Methods
Ten focus groups were conducted in southern West Virginia and included five groups of men and five groups of women. Cultural norms associated with residents of rural Appalachia, such as faith, family values, and patriarchy, were examined.
Results
Both men and women in the focus groups have a sense of place, strong family ties, and a strong spiritual belief or faith in God. Patriarchy as a cultural value was not a strong factor.
Conclusion
There are limits to how qualitative data may be used, but findings from this study help increase understanding of the social and cultural environments of people living in rural Appalachia and how these environments may affect health.
PMCID: PMC1779288  PMID: 16978499
5.  Assessing the burden of HPV-related cancers in Appalachia 
Appalachia is a geographic region with existing cancer disparities, yet little is known about its burden of HPV-related cancers outside of cervical cancer. We assessed the burden of HPV-related cancers in three Appalachian states and made comparisons to non-Appalachian regions. We examined 1996–2008 cancer registry data for Ohio, Kentucky, West Virginia and the Surveillance, Epidemiology and End Results (SEER) 9 program. For each gender, we calculated age-adjusted incidence rates per 100,000 population for each HPV-related cancer type (cervical, vaginal, vulvar, penile, anal and oral cavity and pharyngeal cancers) and all HPV-related cancers combined. Incidence rates among females for all HPV-related cancers combined were higher in Appalachian Kentucky [24.6 (95% CI: 23.5–25.7)], West Virginia [22.8 (95% CI: 22.0–23.6)] and Appalachian Ohio [21.9 (95% CI: 21.0–22.8)] than SEER 9 [18.8 (95% CI: 18.6–19.0)]. Similar disparities were found among females when examining cervical and vulvar cancers separately. Among males, Appalachian [21.3 (95% CI: 20.2–22.4)] and non-Appalachian [21.9 (95% CI: 21.2–22.7)] Kentucky had higher incidence rates for all HPV-related cancers combined than SEER 9 [18.3 (95% CI: 18.1–18.6)]. The incidence rate of all HPV-related cancers combined was higher among males from Appalachian Ohio compared with those from non-Appalachian Ohio [17.6 (95% CI: 16.8–18.5) vs. 16.3 (95% CI: 16.0–16.6)]. Our study suggests that HPV-related cancer disparities exist in Appalachia beyond the known high cervical cancer incidence rates. These results have important public health implications by beginning to demonstrate the potential impact that widespread HPV vaccination could have in Appalachia.
doi:10.4161/hv.22389
PMCID: PMC3667951  PMID: 23143774
Human papillomavirus; HPV; Cancer; Appalachia; Disparities
6.  Hygiene Self-Care of Older Adults in West Virginia: Effects of Gender 
Purpose
This study investigated whether oral hygiene self-care behavior differs between genders in older adults in Appalachia, a geographic area with significant oral health concerns. Identifying the practices of older adults may provide valuable information for designing interventions, and improving overall oral health outcomes.
Methods
As part of a larger, on-going study on cognition and oral health in later life in Appalachia, a sample of dentate, older adults without dementia aged 70 and above (n =245, 86 men and 159 women) received an oral assessment by either a dentist or dental hygienist. Psychometricians assessed cognition using a standardized battery of neuropsychological tests. They also administered the General Oral Health Assessment Index and conducted structured interviews concerning diet, oral hygiene practices, oral health, social support, income, and years of education.
Results
Over 80% of women (n = 128) and 52.3% of men (n = 45) reported brushing their teeth twice daily. Multivariate logistic regression analysis was conducted, controlling for socioeconomic status, social support (i.e., frequency of contacting friends and relatives), general oral health assessment items, number of decayed, missing, and filled surfaces, plaque index, and having regular dental visits. The results showed that women reported more frequent toothbrushing than their male counterparts (OR=4.04, 95% CI:1.93,8.42).
Conclusion
Older women in West Virginia had significantly better oral hygiene practices than older men, particularly regarding toothbrushing. Interventions are needed to improve older men’s dental hygiene behaviors to improve overall oral health outcomes.
PMCID: PMC3607540  PMID: 22947846
aged; self-care; gender differences; preventive behavior; Appalachia; oral hygiene
7.  White Infant Mortality in Appalachian States, 1976-1980 and 1996-2000: Changing Patterns and Persistent Disparities 
Purpose
Appalachian counties have historically had elevated infant mortality rates. Changes in infant mortality disparities over time in Appalachia are not well-understood. This study explores spatial inequalities in white infant mortality rates over time in the 13 Appalachian states, comparing counties in Appalachia with non-Appalachian counties.
Methods
Data are analyzed for 1,100 counties in 13 Appalachian states that include 420 counties designated as Appalachian by the Appalachian Regional Commission. Area Resource File data for 1976-1980 and 1996-2000 provide county- and city-level infant mortality rates, poverty rates, rural-urban continuum codes, and numbers of physicians per 1,000 residents. Multiple regression analyses evaluate whether Appalachian counties are significantly associated with elevated white infant mortality in each time period, accounting for covariates.
Findings
White infant mortality rates decreased substantially in all sub-regions over the last 2 decades; however, disparities in infant mortality did not diminish in Appalachian counties compared to non-Appalachian counties. After accounting for poverty, rural/urban status, and health care resources, Appalachian counties were significantly associated with comparatively higher infant mortality during the late 1970s but not in the late 1990s. At the more recent time point, higher poverty rates, residence in more rural areas, and lower physician density were associated with greater infant mortality risk.
Conclusion
Appalachian counties continue to experience relatively elevated infant mortality rates. Poverty and rurality remain important dimensions of health service need in Appalachia.
doi:10.1111/j.1748-0361.2011.00385.x
PMCID: PMC3733175  PMID: 22458318
Appalachia; disparity; infant mortality; rural
8.  Formative Research Conducted in Rural Appalachia to Inform a Community Physical Activity Intervention 
Purpose
Despite the well-established benefits of physical activity (PA), most Americans, especially those in rural, traditionally underserved areas, engage in considerably less PA than recommended. This study examines perceived barriers to and facilitators of PA and promising organized PA programs among rural Appalachians.
Design
Eight focus groups and seven group key informant interviews were conducted.
Setting
This study was conducted in eastern Kentucky, in Central Appalachia.
Subjects
114 rural Appalachian residents (74% female, 91% White) participated.
Measures
Open-ended, semi-structured, and structured questions regarding perceptions of, barriers to/facilitators of, and examples of successful/failed PA programs were asked.
Analysis
Qualitative data analysis was conducted, including codebook development and steps taken to ensure rigor and transferability. Interrater reliability was over 94%.
Results
In addition to barriers that are consistent with other populations, rural Appalachian residents indicated that travel time, family commitments, and inadequate community resources undermine PA. Suggested avenues to increase PA include partnership with churches and the U.S. Cooperative Extension Service; programs that include families, are well-advertised, focus on health rather than appearance; and, underlying all suggestions, culturally-relevant yet non-stereotyping activities.
Conclusions
When developing PA interventions in rural Appalachia, it is important to employ community-based participatory approaches that leverage unique assets of the population and show potential in overcoming challenges to PA.
doi:10.4278/ajhp.091223-QUAL-399
PMCID: PMC3252212  PMID: 22208411
Physical activity; Appalachia; community-based research; Manuscript format: research; Research purpose: descriptive; Study design: qualitative; Outcome measure: cognitive; Setting: local community; Health focus: fitness/physical activity; Strategy: education, skill building/behaviors change; Target population age: youth, adults, seniors; Target population characteristics: geographic location, underserved
9.  Taste Genes Associated with Dental Caries 
Journal of dental research  2010;89(11):1198-1202.
Dental caries is influenced by a complex interplay of genetic and environmental factors including dietary habits. Previous reports have characterized the influence of genetic variation on taste preferences and dietary habits. We therefore hypothesized that genetic variation in taste pathway genes (TAS2R38, TAS1R2, GNAT3) may be associated with dental caries risk and/or protection. Families were recruited by the Center for Oral Health Research in Appalachia (COHRA) for collection of biological samples, demographic data and clinical assessment of oral health including caries scores. Multiple single nucleotide polymorphism (SNP) assays for each gene were performed and analyzed using transmission disequilibrium test (TDT) analysis (FBAT software) for three dentition groups: primary, mixed, and permanent. Statistically significant associations were seen in TAS2R38 and TAS1R2 for caries risk and/or protection.
doi:10.1177/0022034510381502
PMCID: PMC2954250  PMID: 20858777
Dental Caries; Genetics; Taste Genes; Taste Preference; Association Analysis
10.  Taste Genes Associatedwith Dental Caries 
Journal of Dental Research  2010;89(11):1198-1202.
Dental caries is influenced by a complex interplay of genetic and environmental factors, including dietary habits. Previous reports have characterized the influence of genetic variation on taste preferences and dietary habits. We therefore hypothesized that genetic variation in taste pathway genes (TAS2R38, TAS1R2, GNAT3) may be associated with dental caries risk and/or protection. Families were recruited by the Center for Oral Health Research in Appalachia (COHRA) for collection of biological samples, demographic data, and clinical assessment of oral health, including caries scores. Multiple single-nucleotide polymorphism (SNP) assays for each gene were performed and analyzed by transmission disequilibrium test (TDT) analysis (FBAT software) for three dentition groups: primary, mixed, and permanent. Statistically significant associations were seen in TAS2R38 and TAS1R2 for caries risk and/or protection.
doi:10.1177/0022034510381502
PMCID: PMC2954250  PMID: 20858777
dental caries; taste preference; genetic association; taste pathway genes
11.  Appalachian versus non-Appalachian US traffic fatalities, 2008-2010 
Annals of epidemiology  2013;23(6):377-380.
Purpose
Though myriad health disparities exist in Appalachia, limited research has examined traffic fatalities in the region. This study compared traffic-fatality rates in Appalachia and the non-Appalachian US.
Methods
Fatality Analysis Reporting System and Census data from 2008-2010 were used to calculate traffic-fatality rates. Poisson models were used to estimate unadjusted (RR) and adjusted rate ratios (aRR), controlling for age, sex, and county-specific population density levels. Results: The Appalachian traffic-fatality rate was 45% (95% CI: 1.42, 1.47) higher than the non-Appalachian rate. Though only 29% of fatalities occur in rural counties in non-Appalachia versus 48% in Appalachia, rates in rural counties were similar (RR=0.97; 95% CI: 0.95, 1.00). However, the rate for urban, Appalachian counties was 42% (95% CI: 1.38, 1.45) higher than among urban, non-Appalachian counties. Appalachian rates were higher for passenger-vehicle drivers, motorcyclists, and all-terrain-vehicle riders, regardless of rurality, as well as for passenger-vehicle passengers overall and for urban counties. Conversely, Appalachia experienced lower rates among pedestrians and bicyclists, regardless of rurality.
Conclusions
Disparities in traffic fatality rates exist in Appalachia. Though elevated rates are partially explained by the proportion of residents living in rural settings, overall rates in urban Appalachia were consistently higher than in urban non-Appalachia.
doi:10.1016/j.annepidem.2013.04.001
PMCID: PMC3689544  PMID: 23619016
Accidents; Appalachia; health disparities
12.  Cultural Perspectives Concerning Adolescent Use of Tobacco and Alcohol in the Appalachian Mountain Region 
Context
Appalachia has high rates of tobacco use and related health problems, and despite significant impediments to alcohol use, alcohol abuse is common. Adolescents are exposed to sophisticated tobacco and alcohol advertising. Prevention messages, therefore, should reflect research concerning culturally influenced attitudes toward tobacco and alcohol use.
Methods
With 4 grants from the National Institutes of Health, 34 focus groups occurred between 1999 and 2003 in 17 rural Appalachian jurisdictions in 7 states. These jurisdictions ranged between 4 and 8 on the Rural-Urban Continuum Codes of the Economic Research Service of the US Department of Agriculture. Of the focus groups, 25 sought the perspectives of women in Appalachia, and 9, opinions of adolescents.
Findings
The family represented the key context where residents of Appalachia learn about tobacco and alcohol use. Experimentation with tobacco and alcohol frequently commenced by early adolescence and initially occurred in the context of the family home. Reasons to abstain from tobacco and alcohol included a variety of reasons related to family circumstances. Adults generally displayed a greater degree of tolerance for adolescent alcohol use than tobacco use. Tobacco growing represents an economic mainstay in many communities, a fact that contributes to the acceptance of its use, and many coal miners use smokeless tobacco since they cannot light up in the mines. The production and distribution of homemade alcohol was not a significant issue in alcohol use in the mountains even though it appeared not to have entirely disappeared.
Conclusions
Though cultural factors support tobacco and alcohol use in Appalachia, risk awareness is common. Messages tailored to cultural themes may decrease prevalence.
doi:10.1111/j.1748-0361.2008.00139.x
PMCID: PMC2409582  PMID: 18257873
13.  Cancer Screening Practices Among Amish and Non-Amish Adults Living in Ohio Appalachia 
Purpose
The Amish, a unique community living in Ohio Appalachia, have lower cancer incidence rates than non-Amish living in Ohio Appalachia. The purpose of this study was to examine cancer screening rates among Amish compared to non-Amish adults living in Ohio Appalachia and a national sample of adults of the same race and ethnicity in an effort to explain cancer patterns.
Methods
Face-to-face interviews focusing on perception of risk, cancer screening behaviors, and screening barriers were conducted among Amish (n=134) and non-Amish (n=154) adults living in Ohio Appalachia. Cancer screening rates were calculated and then compared to a national sample of adults.
Findings
More Ohio Appalachia non-Amish males (35.9% vs 14.5%; P = .022) and females (33.3% vs 12.5%; P = .008) reported that they would probably develop cancer in the future compared to Amish males and females. Amish adults had significantly lower prostate (13.5% vs 63.1% vs 44.6%; P < .001), colorectal (males: 10.3% vs 40.0% vs 37.2%, females: 8.6% vs 31.6% vs 42.9%; P < .001), cervical (48.0% vs 84.0% vs 80.0%; P < .001), and female breast (24.8% vs 53.7% vs 56.9%; P < .05) cancer screening rates compared to Ohio Appalachia non-Amish participants and a national sample of adults, respectively. Barriers to cancer screening were similar among the 2 Ohio groups; however, Amish males reported that prostate cancer screening was not necessary more often than did Ohio Appalachia non-Amish males (78.6% vs 16.7%; P = .003).
Conclusions
Lower rates of cancer screening were documented among the Amish and may be a contributing factor to the reduced cancer incidence rates reported among this population.
doi:10.1111/j.1748-0361.2010.00345.x
PMCID: PMC3130935  PMID: 21729158
Amish; Appalachia; health disparities; health promotion; medical care
14.  Transition from first illicit drug use to first injection drug use among rural Appalachian drug users: A cross-sectional comparison and retrospective survival analysis 
Addiction (Abingdon, England)  2011;107(3):587-596.
Aim
The study's objectives were to characterize initiation of injection drug use, examine the independent association of specific substance use with injection drug use, and determine factors associated with rates of transition from first illicit drug use to first injection among a sample of rural Appalachian drug users.
Design
Interview-administered questionnaires were administered to a sample of drug users recruited via respondent-driven sampling.
Setting
Appalachian Kentucky
Participants
Injection drug users (IDUs) (n=394) and non-IDUs (n=109)
Measurements
Data were collected on substance use and years from age at initiation of illicit substance use to ‘event’ (initiation of injection or date of baseline interview for non-IDUs). Logistic regression and Cox regression were used to identify factors associated with lifetime injection drug use and transition time to injection, respectively.
Findings
OxyContin® was involved in nearly as many initiations to injection (48%) as were stimulants, other prescription opioids, and heroin combined; for participants who initiated with OxyContin®, the median time from which they began OxyContin® use to their first injection of OxyContin® was 3 years. Adjusting for demographics, five prescription drugs (benzodiazepines, illicit methadone, oxycodone, OxyContin® and other opiates) were associated with an increased hazard for transitioning from first illicit drug use to first injection drug use (each at p<.01).
Conclusions
In Appalachia, in the US, the prescription opioid, OxyContin®, is widely used nonmedically and appears to show a particularly high risk of rapid transition to injection compared with the use of other illicit drugs.
doi:10.1111/j.1360-0443.2011.03635.x
PMCID: PMC3262084  PMID: 21883604
15.  Ohio Appalachian Women’s Perceptions of the Cost of Cervical Cancer Screening 
Cancer  2010;116(20):4727-4734.
Background
Despite evidence of the importance of cervical cancer screening, screening rates in the United States remain below national prevention goals. Women in the Appalachia Ohio region have higher cervical cancer incidence and mortality rates along with lower cancer screening rates. This study explored Appalachian Ohio women’s expectations about Pap test cost and perceptions of cost as a barrier to screening.
Methods
Face-to-face interviews were conducted with 571 women who were part of a multilevel observational community-based research program in Appalachia Ohio. Eligible women were identified through 14 participating health clinics and asked questions about Pap test cost and perceptions of cost as a barrier to screening. Estimates of medical costs were compared to actual costs reported by clinics.
Results
When asked about how much a Pap test would cost, 80% of the women reported they did not know. Among women who reportedly believed they knew the cost, 40% overestimated test cost. Women who noted cost as a barrier were twice as likely to not receive a test within screening guidelines as those who did not perceive a cost barrier. Further, uninsured women were more than 8.5 times as likely to note cost as a barrier than women with private insurance.
Conclusions
While underserved women in need of cancer screening commonly report cost as a barrier, these findings suggest that women may have a very limited and often inaccurate understanding about Pap test cost. Providing women with this information may help reduce the impact of this barrier to screening.
doi:10.1002/cncr.25491
PMCID: PMC3052694  PMID: 20597135
Pap test; disparities; perception of cost; access; cost barriers; underserved populations; Appalachia; cancer screening
16.  Mortality in Appalachian Coal Mining Regions: The Value of Statistical Life Lost 
Public Health Reports  2009;124(4):541-550.
SYNOPSIS
Objectives
We examined elevated mortality rates in Appalachian coal mining areas for 1979–2005, and estimated the corresponding value of statistical life (VSL) lost relative to the economic benefits of the coal mining industry.
Methods
We compared age-adjusted mortality rates and socioeconomic conditions across four county groups: Appalachia with high levels of coal mining, Appalachia with lower mining levels, Appalachia without coal mining, and other counties in the nation. We converted mortality estimates to VSL estimates and compared the results with the economic contribution of coal mining. We also conducted a discount analysis to estimate current benefits relative to future mortality costs.
Results
The heaviest coal mining areas of Appalachia had the poorest socioeconomic conditions. Before adjusting for covariates, the number of excess annual age-adjusted deaths in coal mining areas ranged from 3,975 to 10,923, depending on years studied and comparison group. Corresponding VSL estimates ranged from $18.563 billion to $84.544 billion, with a point estimate of $50.010 billion, greater than the $8.088 billion economic contribution of coal mining. After adjusting for covariates, the number of excess annual deaths in mining areas ranged from 1,736 to 2,889, and VSL costs continued to exceed the benefits of mining. Discounting VSL costs into the future resulted in excess costs relative to benefits in seven of eight conditions, with a point estimate of $41.846 billion.
Conclusions
Research priorities to reduce Appalachian health disparities should focus on reducing disparities in the coalfields. The human cost of the Appalachian coal mining economy outweighs its economic benefits.
PMCID: PMC2693168  PMID: 19618791
17.  Academic detailing to increase colorectal cancer screening by primary care practices in Appalachian Pennsylvania 
Background
In the United States, colorectal cancer (CRC) is the third most frequently diagnosed cancer and second leading cause of cancer death. Screening is a primary method to prevent CRC, yet screening remains low in the U.S. and particularly in Appalachian Pennsylvania, a largely rural area with high rates of poverty, limited health care access, and increased CRC incidence and mortality rates. Receiving a physician recommendation for CRC screening is a primary predictor for patient adherence with screening guidelines. One strategy to disseminate practice-oriented interventions is academic detailing (AD), a method that transfers knowledge or methods to physicians, nurses or office staff through the visit(s) of a trained educator. The objective of this study was to determine acceptability and feasibility of AD among primary care practices in rural Appalachian Pennsylvania to increase CRC screening.
Methods
A multi-site, practice-based, intervention study with pre- and 6-month post-intervention review of randomly selected medical records, pre- and post-intervention surveys, as well as a post-intervention key informant interview was conducted. The primary outcome was the proportion of patients current with CRC screening recommendations and having received a CRC screening within the past year. Four practices received three separate AD visits to review four different learning modules.
Results
We reviewed 323 records pre-intervention and 301 post-intervention. The prevalence of being current with screening recommendation was 56% in the pre-intervention, and 60% in the post-intervention (p = 0. 29), while the prevalence of having been screened in the past year increased from 17% to 35% (p < 0.001). Colonoscopies were the most frequently performed screening test. Provider knowledge was improved and AD was reported to be an acceptable intervention for CRC performance improvement by the practices.
Conclusions
AD appears to be acceptable and feasible for primary care providers in rural Appalachia. A ceiling effect for CRC screening may have been a factor in no change in overall screening rates. While the study was not designed to test the efficacy of AD on CRC screening rates, our evidence suggests that AD is acceptable and may be efficacious in increasing recent CRC screening rates in Appalachian practices which could be tested through a randomized controlled study.
doi:10.1186/1472-6963-11-112
PMCID: PMC3128846  PMID: 21600059
18.  Assessing Awareness and Knowledge of Breast and Cervical Cancer Among Appalachian Women 
Preventing Chronic Disease  2006;3(4):A125.
Introduction
West Virginia is the only state that lies entirely within Appalachia. West Virginians tend to be poorer and more likely to lack health insurance than the general U.S. population. The purpose of this qualitative study was to 1) obtain an understanding of attitudes about breast and cervical cancer screening among women aged 25 to 64 years; 2) determine factors that motivate women to be screened for breast and cervical cancer; and 3) evaluate educational materials about breast and cervical cancer screening for use in this population.
Methods
The West Virginia Breast and Cervical Cancer Screening Program (WVBCCSP) is a comprehensive public health program, funded by the Centers for Disease Control and Prevention, dedicated to removing barriers to breast and cervical cancer screening and providing screenings to underserved women aged 25 to 64 years. The program partnered with RMS Strategies, Inc, to conduct six focus groups in three communities in West Virginia. Women were recruited by telephone based on program eligibility guidelines.
Results
Results indicated that women were concerned about health care costs and lack of health insurance. Cost, fear, and embarrassment were identified as the top barriers to breast and cervical cancer screening. Participants believed that community-based educational campaigns would increase screening and promote use of the WVBCCSP.
Conclusion
Understanding why low-income Appalachian women do not get screened for breast and cervical cancer and determining motivational factors that encourage screening are important to increase screening rates among this population. Breast and cervical cancer efforts that use the words, knowledge, and suggestions of the women they serve are more likely to be effective and have a larger impact.
PMCID: PMC1779289  PMID: 16978500
19.  A Comparative Analysis of Health-Related Quality of Life for Residents of U.S. Counties with and without Coal Mining 
Public Health Reports  2010;125(4):548-555.
SYNOPSIS
Objectives
We compared health-related quality of life (HRQOL) in mining and non-mining counties in and out of Appalachia using the 2006 Behavioral Risk Factor Surveillance System (BRFSS) survey.
Methods
Dependent variables included self-rated health, the number of poor physical and mental health days, the number of activity limitation days (in the last 30 days), and the Centers for Disease Control and Prevention Healthy Days Index. Independent variables included the presence of coal mining, Appalachian region residence, metropolitan status, primary care physician supply, and BRFSS behavioral (e.g., smoking, body mass index, and alcohol consumption) and demographic (e.g., age, gender, race, and income) variables. We compared dependent variables across a four-category variable: Appalachia (yes/no) and coal mining (yes/no). We used SUDAAN® Multilog and multiple linear regression models with post-hoc least-squares means to test for Appalachian coal-mining effects after adjusting for covariates.
Results
Residents of coal-mining counties inside and outside of Appalachia reported significantly fewer healthy days for both physical and mental health, and poorer self-rated health (p<0.0005) when compared with referent U.S. non-coal-mining counties, but disparities were greatest for people residing in Appalachian coal-mining areas. Furthermore, results remained consistent in separate analyses by gender and age.
Conclusions
Coal-mining areas are characterized by greater socioeconomic disadvantage, riskier health behaviors, and environmental degradation that are associated with reduced HRQOL.
PMCID: PMC2882606  PMID: 20597455
20.  Age at diagnosis of diabetes in Appalachia 
Background
Appalachia is a region of the United States noted for the poverty and poor health outcomes of its residents. Residents of the poorest Appalachian counties have a high prevalence of diabetes and risk factors (obesity, low income, low education, etc.) for type 2 diabetes. However, diabetes prevalence exceeds what these risk factors alone explain. Based on this, the history of poor health outcomes in Appalachia, and personally observed high rates of childhood obesity and lack of concern about prediabetes, we speculated that people in Appalachia with diagnosed diabetes might tend to be diagnosed younger than their non-Appalachian counterparts.
Methods
We used data from the Behavioral Risk Factor Surveillance System (2006-2008). We compared age at diagnosis among counties by Appalachian Regional Commission-defined level of economic development. To account for risk differences, we constructed a model for average age at diagnosis of diabetes, adjusting for county economic development, obesity, income, sedentary lifestyle, and other covariates.
Findings
After adjustment for risk factors for diabetes, people in distressed or at-risk counties (the least economically developed) had their diabetes diagnosed two to three years younger than comparable people in non-Appalachian counties. No significant differences between non-Appalachian counties and Appalachian counties at higher levels of economic development remained after adjusting.
Conclusions
People in distressed and at-risk counties have poor access to care, and are unlikely to develop diabetes at the same age as their non-Appalachian counterparts but be diagnosed sooner. Therefore, people in distressed and at-risk counties are likely developing diabetes at younger ages. We recommend that steps to reduce health disparities between the poorest Appalachian counties and non-Appalachian counties be considered.
doi:10.1186/1478-7954-9-54
PMCID: PMC3203846  PMID: 21961697
Appalachia; Diabetes: Disparities; Geography
21.  Cultural and community determinants of subjective social status among Cherokee and White youth 
Ethnicity & health  2008;13(4):289-303.
Background
Subjective social status (SSS) is associated with physical and mental health in diverse samples. However, community, cultural, and ethnic influences on SSS are poorly understood, especially among rural and American Indian populations.
Objective
We aimed to examine similarities and differences in how community poverty, family context, and life course attainment predict SSS among Cherokee and White youth in Appalachia.
Design
We assessed culturally and developmentally appropriate aspects of life course attainment among 344 Cherokee and White youth (age 19–24) using the Life Trajectory Interview for Youth (Brown et al. 2006. International Journal of Methods in Psychiatric Research, 15, 192–206). Combined with information regarding community context and family history, these data were used to examine common patterns and ethnic differences in community, family, and cultural influences on SSS.
Results
Overall, both Cherokee and White youth rank their families lower in SSS than previously studied US youth. Family poverty during childhood and low parental education negatively influence family SSS, Cherokee youth rank higher on subjective socioeconomic status (SES) than Whites, as do participants in high poverty areas. However, White youth rank higher on peer SSS. Ethnographically generated items perform better than standard demographic markers in predicting SSS. Educational attainment is associated with peer SSS among Cherokee (but not White) youths.
Conclusions
Cultural identity, community context, and local reference groups are crucial determinants of SSS. Both White and Cherokee youth in Appalachia exhibit SSS rankings consistent with socioeconomic and cultural marginalization. On a local scale, however, living in high poverty areas or minority communities may buffer individuals from some negative social comparisons regarding subjectively perceived SES. Meanwhile, social monitoring in small minority communities may constrain optimistic bias in assessments of peer popularity and status. Social ecology, family context, and individual attainment appear to exert distinctive influences on SSS across different cultural and ethnic groups.
doi:10.1080/13557850701837302
PMCID: PMC4075651  PMID: 18701990
Native American; Appalachia; culture; socioeconomic status; social hierarchy; poverty
22.  Knowledge and Perceptions of Diabetes in an Appalachian Population 
Preventing Chronic Disease  2005;2(2):A13.
Introduction
Qualitative research on knowledge and perceptions of diabetes is limited in the Appalachian region, where social, economic, and behavioral risk factors put many individuals at high risk for diabetes. The aim of this study was to gain a culturally informed understanding of diabetes in the Appalachian region by 1) determining cultural knowledge, beliefs, and attitudes of diabetes among those who live in the region; 2) identifying concerns and barriers to care for those with diabetes; and 3) determining the barriers and facilitators to developing interventions for the prevention and early detection of diabetes in Appalachia.
Methods
Thirteen focus groups were conducted in 16 counties in West Virginia in 1999. Seven of the groups were composed of persons with diabetes (n = 61), and six were composed of community members without diabetes (n = 40). Participants included 73 women and 28 men (n = 101).
Results
Findings show that among this population there is lack of knowledge about diabetes before and after diagnosis and little perception that a risk of diabetes exists (unless there is a family history of diabetes). Social interactions are negatively affected by having diabetes, and cultural and economic barriers to early detection and care create obstacles to the early detection of diabetes and education of those diagnosed.
Conclusion
Public health education and community-level interventions for primary prevention of diabetes in addition to behavior change to improve the management of diabetes are needed to reduce the health disparities related to diabetes in West Virginia.
PMCID: PMC1327707  PMID: 15888224
23.  The Promise of Prevention: The Effects of Four Preventable Risk Factors on National Life Expectancy and Life Expectancy Disparities by Race and County in the United States 
PLoS Medicine  2010;7(3):e1000248.
Majid Ezzati and colleagues examine the contribution of a set of risk factors (smoking, high blood pressure, elevated blood glucose, and adiposity) to socioeconomic disparities in life expectancy in the US population.
Background
There has been substantial research on psychosocial and health care determinants of health disparities in the United States (US) but less on the role of modifiable risk factors. We estimated the effects of smoking, high blood pressure, elevated blood glucose, and adiposity on national life expectancy and on disparities in life expectancy and disease-specific mortality among eight subgroups of the US population (the “Eight Americas”) defined on the basis of race and the location and socioeconomic characteristics of county of residence, in 2005.
Methods and Findings
We combined data from the National Health and Nutrition Examination Survey and the Behavioral Risk Factor Surveillance System to estimate unbiased risk factor levels for the Eight Americas. We used data from the National Center for Health Statistics to estimate age–sex–disease-specific number of deaths in 2005. We used systematic reviews and meta-analyses of epidemiologic studies to obtain risk factor effect sizes for disease-specific mortality. We used epidemiologic methods for multiple risk factors to estimate the effects of current exposure to these risk factors on death rates, and life table methods to estimate effects on life expectancy. Asians had the lowest mean body mass index, fasting plasma glucose, and smoking; whites had the lowest systolic blood pressure (SBP). SBP was highest in blacks, especially in the rural South—5–7 mmHg higher than whites. The other three risk factors were highest in Western Native Americans, Southern low-income rural blacks, and/or low-income whites in Appalachia and the Mississippi Valley. Nationally, these four risk factors reduced life expectancy at birth in 2005 by an estimated 4.9 y in men and 4.1 y in women. Life expectancy effects were smallest in Asians (M, 4.1 y; F, 3.6 y) and largest in Southern rural blacks (M, 6.7 y; F, 5.7 y). Standard deviation of life expectancies in the Eight Americas would decline by 0.50 y (18%) in men and 0.45 y (21%) in women if these risks had been reduced to optimal levels. Disparities in the probabilities of dying from cardiovascular diseases and diabetes at different ages would decline by 69%–80%; the corresponding reduction for probabilities of dying from cancers would be 29%–50%. Individually, smoking and high blood pressure had the largest effect on life expectancy disparities.
Conclusions
Disparities in smoking, blood pressure, blood glucose, and adiposity explain a significant proportion of disparities in mortality from cardiovascular diseases and cancers, and some of the life expectancy disparities in the US.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Life expectancy (a measure of longevity and premature death) and overall health have increased steadily in the United States over recent years. New drugs, new medical technologies, and better disease prevention have all helped Americans to lead longer, healthier lives. However, even now, some Americans live much longer and much healthier lives than others. Health disparities—differences in how often certain diseases occur and cause death in groups of people classified according to their ethnicity, geographical location, sex, or age—are extremely large and persistent in the US. On average, black men and women in the US live 6.3 and 4.5 years less, respectively, than their white counterparts; the gap between life expectancy in the US counties with the lowest and highest life expectancies is 18.4 years for men and 14.3 years for women. Disparities in deaths (mortality) from chronic diseases such as cardiovascular diseases (for example, heart attacks and stroke), cancers, and diabetes are known to be the main determinants of these life expectancy disparities.
Why Was This Study Done?
Preventable risk factors such as smoking, high blood pressure, excessive body fat (adiposity), and high blood sugar are responsible for many thousands of deaths from chronic diseases. Exposure to these risk factors varies widely by race, state of residence, and socioeconomic status. However, the effects of these observed disparities in exposure to modifiable risk factors on US life expectancy disparities have only been examined in selected groups of people and it is not known how multiple modifiable risk factors affect US health disparities. A better knowledge about how disparities in risk factor exposure contribute to health disparities is needed to ensure that prevention programs not only improve the average health status but also reduce health disparities. In this study, the researchers estimate the effects of smoking, high blood pressure, high blood sugar, and adiposity on US life expectancy and on disparities in life expectancy and disease-specific deaths among the “Eight Americas,” population groups defined by race and by the location and socioeconomic characteristics of their county of residence.
What Did the Researchers Do and Find?
The researchers extracted data on exposure to these risk factors from US national health surveys, information on deaths from different diseases in 2005 from the US National Center for Health Statistics, and estimates of how much each risk factor increases the risk of death from each disease from published studies. They then used modeling methods to estimate the effects of risk factor exposure on death rates and life expectancy. The Asian subgroup had the lowest adiposity, blood sugar, and smoking rates, they report, and the three white subgroups had the lowest blood pressure. Blood pressure was highest in the three black subgroups, whereas the other three risk factors were highest in Western Native Americans, Southern rural blacks, and whites living in Appalachia and the Mississippi Valley. The effects on life expectancy of these factors were smallest in Asians and largest in Southern rural blacks but, overall, these risk factors reduced the life expectancy for men and women born in 2005 by 4.9 and 4.1 years, respectively. Other calculations indicate that if these four risk factors were reduced to optimal levels, disparities among the subgroups in deaths from cardiovascular diseases and diabetes and from cancers would be reduced by up to 80% and 50%, respectively.
What Do These Findings Mean?
These findings suggest that disparities in smoking, blood pressure, blood sugar, and adiposity among US racial and geographical subgroups explain a substantial proportion of the disparities in deaths from cardiovascular diseases, diabetes, and cancers among these subgroups. The disparities in risk factor exposure also explain some of the disparities in life expectancy. The remaining disparities in deaths and life expectancy could be the result of preventable risk factors not included in this study—one of its limitations is that it does not consider the effect of dietary fat, alcohol use, and dietary salt, which are major contributors to different diseases. Thus, suggest the researchers, reduced exposure to preventable risk factors through the implementation of relevant policies and programs should reduce life expectancy and mortality disparities in the US and yield health benefits at a national scale.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000248.
The US Centers for Disease Control and Prevention, the US Office of Minority Health, and the US National Center on Minority Health and Health Disparities all provide information on health disparities in the US
MedlinePlus provides links to information on health disparities and on healthy living (in English and Spanish)
The US Centers for Disease Control and Prevention provides information on all aspects of healthy living
The American Heart Association and the American Cancer Society provide information on modifiable risk factors for patients and caregivers
Healthy People 2010 is a national framework designed to improve the health of people living in the US
The US National Health and Nutrition Examination Survey (NHANES) and the Behavioral Risk Factor Surveillance System (BRFSS) collect information on risk factor exposures in the US
doi:10.1371/journal.pmed.1000248
PMCID: PMC2843596  PMID: 20351772
24.  Appalachian and Non-Appalachian Pediatricians’ Encouragement of the Human Papillomavirus Vaccine: Implications for Health Disparities 
Background
In medically underserved regions such as Appalachia, cervical cancer incidence and mortality are higher than the general U.S. population; therefore, it is important for pediatricians to encourage parents to have their daughters vaccinated against the human papillomavirus (HPV). Unfortunately, little is known about the predictors of pediatricians’ encouragement of the HPV vaccine among medically underserved populations. The current study compared attitudes and behaviors of pediatricians with practices in Appalachia with those in non-Appalachia to identify potential strategies for reducing health disparities.
Methods
A survey was conducted with 334 pediatricians located in Appalachia and non-Appalachia counties to examine how prior behavior, perceived susceptibility, severity, self-efficacy, response-efficacy, and behavioral intentions are related to self-reported vaccine encouragement.
Results
Pediatricians in Appalachia perceived their patients to be less susceptible to HPV and reported lower rates of HPV encouragement than pediatricians in non-Appalachia. In addition, self-efficacy had a significant indirect association with vaccine encouragement for pediatricians in non-Appalachia.
Conclusion
This study’s findings emphasize the importance of increasing Appalachian pediatricians’ awareness of their patients’ susceptibility to HPV. Broader efforts to increase encouragement of the HPV vaccine among pediatricians should focus on promoting self-efficacy to encourage the HPV vaccine to parents of young females.
doi:10.1016/j.whi.2011.07.005
PMCID: PMC3790263  PMID: 21907591
25.  Assessing a multilevel model of young children’s oral health with national survey data 
Objectives
To empirically test a multilevel conceptual model of children’s oral health incorporating 22 domains of children’s oral health across four levels: child, family, neighborhood and state.
Data source
The 2003 National Survey of Children’s Health, a module of the State and Local Area Integrated Telephone Survey conducted by the Centers for Disease Control and Prevention’s National Center for Health Statistics, is a nationally representative telephone survey of caregivers of children.
Study design
We examined child-, family-, neighborhood-, and state-level factors influencing parent’s report of children’s oral health using a multilevel logistic regression model, estimated for 26 736 children ages 1–5 years.
Principal findings
Factors operating at all four levels were associated with the likelihood that parents rated their children’s oral health as fair or poor, although most significant correlates are represented at the child or family level. Of 22 domains identified in our conceptual model, 15 domains contained factors significantly associated with young children’s oral health. At the state level, access to fluoridated water was significantly associated with favorable oral health for children.
Conclusions
Our results suggest that efforts to understand or improve children’s oral health should consider a multilevel approach that goes beyond solely child-level factors.
doi:10.1111/j.1600-0528.2010.00536.x
PMCID: PMC3025295  PMID: 20370808
children’s oral health; multilevel modeling; multiple imputation

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