This piece was recognized by the Kentucky Press Association in 2010. It was awarded First Place for Best Analytical/Enterprise Story in the Daily Class 2 category for the annual Excellence in Kentucky Newspapers Awards.  

The Independent | Progress Edition 2009

ASHLAND Kentucky residents face some serious challenges when it comes to their health.

Recent studies by the U.S. Census bureau, Centers for Disease Control and Prevention and the Appalachian Regional Commission have found that when compared to their counterparts nationwide more Kentuckians suffer from illnesses such as heart disease, diabetes, obesity and certain types of cancer and are more likely to die from those diseases than individuals living elsewhere.

In addition, a high percentage of residents do not have health insurance and live in medically underserved areas. These trends hold particularly true for residents living in the eastern and southern parts of the Commonwealth.

A large number of initiatives are underway across Kentucky and the Appalachia region to address the disparities in health and outcomes.

Marshall University Professor of Family and Community Health Dr. Richard Crespo researches a variety of rural public health topics including chronic disease management and is involved in community health programs across Appalachia. He says there are many underlying factors that contribute to the health challenges the region faces.

Crespo describes the situation as a coin with two sides. The issues on one side, he said, are largely ones of geography, infrastructure and accessibility. On the other side are factors of attitudes, culture and the personal lifestyle choices of individuals.

History and Lifestyle factors

Appalachians have not always been so unhealthy. According to Crespo all one has to do is look at old pictures of individuals in the area, as recently as several decades ago. The people in the photographs are trim and healthy.

Today, by contrast, the Huntington-Ashland-Ironton area has been called the “fattest city in America,” singled out by national media organizations including the Associated Press, Self and Forbes magazines because of some sobering health statistics.

A 2006 report by Forbes Magazine ranking U.S. cities by obesity rates put the rate for the Huntington-Ashland- Ironton obesity rate among adults at 45 percent.

Kentucky ranks seventh in the nation for the prevalence of diabetes and obesity, according to a report by the Trust for America’s Health and the Robert Wood Johnson Foundation. According to the study, 29 percent of Kentucky adults are obese. For Kentucky’s children, the statistics are even more sobering. Kentucky ranks fourth in the percentage of obese children at 37.1 percent of the population between ages 10 and 17. The area also boasts higher rates of cardiovascular disease and diabetes, both of which can be brought on by obesity.

According to Crespo, the transformation to unhealthy has been generational and not all the causes are unique to the area.

Perhaps the biggest changes have come from technology, he said. Fewer individuals now do sweat-breaking manual labor having traded those jobs for sedentary ones.

At the same time, many have also given up walking for driving. Households used to have a single car and as a result, Crespo says, “There was a whole lot more walking going on.”

Another factor that has contributed to obesity and other chronic diseases nationwide is eating habits. The culture has shifted from eating meals at home to eating out, according to Crespo, adding that with that shift came a deadly “combination of high calorie foods and large portions.”

In Appalachia, there is yet another exacerbating factor when it comes to diet. “I don’t want to sound pejorative, but on the other hand in the culture there is a heavy dependence, a tendency, for fried foods and for things like using bacon grease,” he said, “You fix bacon with the green beans otherwise they don’t taste right, good corn bread is made from bacon grease.”

Geography and Poverty

In addition to preference there are some other reasons why Appalachians may not have the healthiest of diets causing them to suffer greater health disparities, according to Crespo.

“There is a strong association in literature between poverty and poor health and it’s not because of a lack of medicine, the association with poverty and poor health comes from in large part from not having access to healthy foods,” he said.

“In rural areas outside of Ashland and Huntington and our other cities, people don’t have access to full service grocery stores there is a reliance on canned foods that are less nutritious than fresh foods and there is less variety. There is also heavy marketing of prepackaged foods,” Crespo said.

In addition, higher rates of unemployment and its resulting poverty also contribute to the health crisis in several ways. “Unemployment is an open door toward an association with a sedentary lifestyle and a lot of that is the psychological affect of being unemployed, it gets a person down, to have to struggle with finances all the time, when you are feeling down its hard to be motivated to do things like be physically active,” according to Crespo.

If a person does become motivated to be physically active there are still even more barriers to overcome in Appalachia than elsewhere. “In rural Appalachia is that there are very few places to be physically active. You cannot walk around the block because there is no block. You walk on the road and then you have to fight the coal trucks. For people to have to go somewhere to be physically active it takes time to go somewhere to do it, you just can’t step out your door,” Crespo said.

It becomes especially harder for individuals with physical limitations who need specific types of facilities, he said. For example, Crespo said he once worked with a woman who had severe arthritis and as a result could not walk very far. “What helped her most were aquatic exercises but she had to drive 45 minutes to get to a place with a pool. That was an hour and a half of driving for a 40 minute session,” Crespo said.

To help address these disparities, Crespo and his staff at MU have developed a number of unique programs involving entire communities. They helped to form diabetes coalitions, which using small grants have reached out to their communities to address many of these issues.

Some coalitions have convinced county and school officials to provide walking tracts at schools. Others have helped to change academic policies to improve physical fitness classes and provide facilities whenever a new school building is constructed.

Access and Affordability

Kentuckians and Appalachians also struggle in many places with affordability and accessibility to health care.

Dr. Michael Karpf, executive vice president of health affairs at the University of Kentucky, says once again the problems in Kentucky are very similar to those nationwide but with a few additional contributing factors. In Kentucky, as elsewhere affordability of insurance and access to it are key issues that contribute to the overall health climate.Both, he said, will hopefully be addressed in pending national legislation.

“We need to have a good, serious, honest debate on what needs to be done with health care. We probably have to change health care substantially to work on efficiency and systems. We need to do the things that have value and not do the things that don’t,” Karpf said.

“There needs to be a real serious discussion on how to be efficient and emphasize quality. I think if there was a focus on that and we were more efficient and a lot less expensive as a system, it would be easier to insure those who do not have insurance now,” he said.

Lack of insurance is a serious problem facing Kentuckians too. Many allow chronic illnesses to go untreated because they lack insurance making their conditions more costly in the long run but also diminishing their quality of life substantially, according to Crespo and Karpf.

According to a 2008 U.S. Census Bureau report on health insurance, 84 percent of Kentuckians are insured. The 16 percent of individuals who are not covered represent 684,000 Kentuckians. Fourteen other states had the same or higher rates of uninsured, the report said.

Nationally, 84.6 percent of Americans – an estimated 255.1 million – had insurance in 2008. The national uninsured rate is estimated at 15.4 percent or 46.3 million. Although 69,973 children in Kentucky lack insurance, 93 percent of Kentucky children are insured slightly above the national average of 90 percent.

Even if a Kentuckian has insurance, many, especially those in rural areas may struggle with access to doctors and medical facilities. “When you get into the rural areas, there are just not enough primary care doctors,” says Karpf, “It means people need to go long distances for routine care, making it much more expensive and harder to do.”

Lack of access to care, can translate in to poorer health outcomes. For example, there are not enough practicing OBGYN’s in many rural areas of Kentucky. “Women routinely have to go 40 to 80 miles to deliver a child and it makes routine prenatal care more difficult,” Karpf said. A lack of prenatal care combined with Kentucky’s high rates of smoking pregnant women has contributed in part to higher statistics in children that are born at low birth weights or premature within Kentucky. Both conditions require additional and expensive care for children throughout their lifetimes and can lead to a diminished quality of life.

Karpf said there several reasons it is hard to attract doctors to rural Kentucky. Along with needing to have an appreciation or living in a rural location, the payer mix among patients is often unattractive. Along with the high numbers of uninsured, Kentucky also has large populations on Medicare and Medicaid.

Attracting and retaining physicians in Kentucky requires a different approach than in urban areas, according to Karpf. “You want to train the right people and you have to come up with different reimbursement approaches that will a make them attractive for them to practice there,” he said.

UK, he said, is highly committed to recruiting and training of rural physicians as well as creating a network of hospitals to treat patients locally. In addition, UK Medical Center also is a hub of regional specialty activity so Kentuckians do not need to travel out of state for highly specialized treatments and procedures. “We try to create a situation where we make it easier to keep people close to home in low cost facilities for common stuff. If they need something specialized then they can get into us rather quickly and easily,” Karpf said.

Moving Forward

Despite the challenges of access to care and availability of insurance, there are things that all Appalachians can do it improve their health and avoid some of the most serious chronic diseases, according to Crespo and Karpf.

“The difficulty in access to medical care contributes to the larger environment of things not just being available, whether it’s healthy foods, opportunities to be physically active or get to your doctor when you need it, all of those bundled together create a mindset,” Crespo said.

“One of the things that I hear regularly from rural areas is people who refer to a relative who had an amputation for diabetes and it’s almost a matter of fact that you reach a certain age and that stuff happens to you. It’s sad because it doesn¹t have to happen,” he said.

His goal is to change that mindset. “It takes a mindset to want to have a healthy lifestyle rather than doing things to prevent disease,” according to Crespo. “By the time we’re conscious of most of the chronic diseases we’ve missed years of opportunities to delay those or prevent their onset.

“The approach that we have found helpful is looking at it from a self-management perspective as opposed to a health professional telling a person what to do,” Crespo said. “What we’re doing is engaging people to make decisions for themselves. Almost everyone is going to be able to identify something that they can do to live out a healthy lifestyle.

A self management perspective is getting people to articulate those things that they know to do and are interested in doing it and then having them make a plan for themselves and starting small. The idea is to get the good habits going. Then our role as health care professionals is to help people along the way as much as possible and we can help them with encouragement with reminders, and with one of the most helpful self management skills – that is problem solving,” Crespo said.

Karpf also sees individual and institutional roles in improving health care statewide. “When addressing the health care needs of Kentucky it has to be a partnership between the citizens of the commonwealth and the physicians. In the long term the most important thing that Kentucky needs to do is modify lifestyle issues, people have to exercise and eat right and have to make sure they don’t get overwhelmingly obese. Those things, changing lifestyles, will make a huge difference,” he said.