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Challenging the Kentucky “Uglies”

Part of a continuing Forefront series examining eastern Kentucky.

Organizations such as Kentucky Homeplace have been working in eastern Kentucky to reduce health disparities and build a healthier and more productive population and a stronger regional economy.

Back in 2014, the New York Times released a ranking of the “hardest places to live.” It synthesized several education, health, and economic metrics for nearly every county in the United States. Eastern Kentucky contained 6 of the 10 lowest-ranked counties out of the more than 3,000 measured. Understandably, residents of these counties were hurt. Here was yet another blanket analysis, missing the local nuances and adding yet another story to a region regularly inundated with negative press. Dr. Fran Feltner, director of Kentucky Homeplace, remarks that “We don’t consider it the hardest place to live. We have community ties with the people here. Our aim is to work on the issues that affect our community and make conditions better for our neighbors and friends.”

Lee Todd Jr., a former University of Kentucky president, referred to these types of studies as the “Kentucky uglies.”

But underlying many of these types of rankings is a hard layer of truth, particularly regarding the health of the region’s residents. Since 2010, the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute have collaborated on the County Health Rankings & Roadmaps program, which tracks nearly every county in the United States. The program looks at a host of measures in an effort to present a more nuanced ranking of a county’s level of health. Counties are ranked separately by health outcomes (how long people live and how well they feel) and health factors (behavioral and social). In the 2016 ranking of Kentucky counties by health outcomes, the bottom 20 counties were all in eastern Kentucky; and when ranking health factors, 19 of the bottom 20 were in eastern Kentucky.

Photograph of Harlan County’s Little Shepherd Trail, courtesy of Karen Pratt.

Photograph of Harlan County’s Little Shepherd Trail, courtesy of Karen Pratt.

The region isn’t the only one that scores poorly in health rankings, but it’s in a difficult position, in the midst of a thousands-strong deluge of unemployed coalminers and battered with high levels of generational poverty, unemployment, and drug abuse.

Yet, what may be a surprise to some is that improving the health of a region’s residents can have a far-reaching impact on the region’s economic stability and lead to vibrant, thriving communities.

Three things to know about the region’s health

Before viewing examples of organizations and programs working to improve health in eastern Kentucky, it may help to look at 3 things.

Life expectancy at birth in eastern Kentucky is lower than the national average, and the gap has been widening over time.

A male born in 1985 in eastern Kentucky could expect to live 68.5 years, or have a lifespan roughly 2 years shorter than the national average. Fast forward 27 years to 2012, and a male born in eastern Kentucky that year could expect to live nearly 6 years fewer than the national average. To put it another way, from 1985 to 2012, the US life expectancy for males increased nearly 6 years; but in eastern Kentucky, the increase was less than one-third of the national gain, at just 1.6 years. This divergence from the national rate is seen, too, in females born in eastern Kentucky, where the life expectancy at birth has actually declined by a year, from 76.9 years in 1985 to 75.9 years in 2012. The widening gap in life expectancies between those of eastern Kentucky and those of the nation overall is driven by a variety of reasons, among them high rates of lung cancer, heart disease, diabetes, smoking, and obesity.

The number of disabled workers per capita in eastern Kentucky is roughly 3 times greater than the nation’s.

In 2015, eastern Kentucky’s per capita rate of disabled workers was nearly 3 times the national rate, according to data from the Social Security Administration. That’s roughly 800 disabled workers for every 10,000 people in eastern Kentucky, an increase of 25 percent from the 2004 rate.

According to work done by the Center on Budget and Policy Priorities, there are 4 factors that influence a region’s disability rate that apply to eastern Kentucky and to Appalachia in general:

  1. A less-educated workforce that has more difficulty switching employment sectors when unemployed
  2. An older workforce that is more likely than a younger workforce to develop disabling conditions
  3. A lower number of immigrants who are less likely to collect disability benefits largely because of program rules
  4. A large share of physically demanding jobs that take a bodily toll, such as mining and manufacturing

Eastern Kentucky is older and aging faster than the nation.

The share of eastern Kentucky’s population that is more than 40 years old is larger than the nation’s—4 percentage points greater—and that share is growing faster than the nation’s, 1.5 times faster from 2009 to 2014, the most recent 5-year period for which we have data.

Changing the trajectory of Kentuckians’ health

There are many organizations working in the region to address health disparities, and Kentucky Homeplace is one. Founded in 1994, Kentucky Homeplace, which covers 30 counties located in eastern Kentucky, was developed by the University of Kentucky’s Center for Excellence in Rural Health to help address health gaps in eastern Kentucky. The need was especially great given the unusually large number of residents with high blood pressure and conditions such as diabetes, cancer, asthma, and heart disease. A variety of factors contribute to these conditions: inadequate health insurance, limited knowledge of how to utilize healthcare, environmental factors, and lifestyle choices, for example.

A majority of Kentucky’s 120 counties are designated “medically underserved areas,” or MUAs, which are areas that have too few primary care providers, high infant mortality, high poverty, or a large older-adult population. An MUA can include a whole county or a group of contiguous counties.

Residents in an MUA experience a shortage of personal health services and may include groups of persons within an area of residence who face economic, cultural, or linguistic barriers to healthcare.

Residents of MUAs are less likely to have medical coverage, are poorer and less educated than residents in other parts of the state, have inadequate transportation, and have less information about available services and their personal health conditions.

Kentucky Homeplace is located in the eastern Kentucky coalmining town of Hazard, and for more than 20 years, this community health initiative has linked tens of thousands of Kentucky residents from rural areas to medical, social, and environmental services. These are residents who otherwise may not have received even limited services or would have simply gone without services of any kind.

The services at Homeplace are offered at no charge to its clients. Beneficiaries from the program are the medically underserved, and most are at 100 percent to 133 percent of the federal poverty level, a guideline based on household income and size that is used to help determine eligibility for a number of assistance programs. In 2016, “poverty level” translated to a household income of less than $24,300 annually for a family of 4.

A critical piece to the success of Kentucky Homeplace is the role of community health workers (CHW).

CHWs are lay health workers selected from the communities in which they reside. Lay health workers are trained in the context of intervention, but they have no formal degree in medicine. Their mission is to overcome barriers to help improve clients’ access to healthcare and to assist in acquiring crucial resources such as eyeglasses, dentures, home heating assistance, food, diabetic supplies, and free medical care.

Because each CHW is a community member, he or she knows the community, residents, and service providers in the area. CHWs are better able to assist with residents’ access to medical, social, and environmental services and to deliver education on prevention and disease self-management. This commonality builds patient trust and facilitates provider sensitivity regarding clients’ health disparities and special needs. In this way, CHWs aid in others’ overcoming economic, physical, social, and cultural health inequities.

In many capacities, CHWs provide an important bridge among clients with the highest need, primary care physicians, and other health providers in the community. They assist in facilitating communication between clients and physicians, aid clients to effectively comply with medical care instructions, and help educate clients to improve their health behaviors related to nutrition, physical activity, weight self-management, smoking cessation, and diabetes self-management.

Tying it all together

The economic impact stemming from the increasingly rapid decline of the coal mining industry has taken center stage in eastern Kentucky. What perhaps gets overlooked is the connection between the health of a region’s population and how it impacts that region’s economy. For some time, eastern Kentucky residents have suffered from lower life expectancies and higher rates of disability and a population whose average age is increasing faster than the nation’s overall as young people leave the region.

To some extent, this rapid physical decline can be attributed to the region’s dependence on mining and manufacturing jobs, professions that are physically demanding.

Recent county health rankings produced by a variety of news outlets have exposed the region’s health disparities to a wider audience. Whether doing so leads to increased investment to improve the health outcomes of the region’s residents remains to be seen. In short, however, a healthy population is a more productive population, and a more productive population creates a stronger regional economy.

Sum and substance: Organizations in eastern Kentucky are working with the population to help overcome negative health outcomes, such as decreasing life expectancy and high levels of disability, that impact eastern Kentuckians’ health and wellness.

Source file:

Eastern Kentucky refers to the 31 coal producing counties in 1988: Bell, Boyd, Breathitt, Carter, Clay, Clinton, Elliot, Floyd, Greenup, Harlan, Jackson, Johnson, Knott, Knox, Laurel, Lawrence, Lee, Leslie, Letcher, McCreary, Magoffin, Martin, Morgan, Owsley, Perry, Pike, Pulaski, Rockcastle, Wayne, Whitley, and Wolfe.

Analysis, reports, and data on per capita rates of disabled workers are available from the Social Security Administration at

For more information regarding the factors that influence a region’s disability rate, see Kathy A. Ruffing’s “Geographic Pattern of Disability Receipt Largely Reflects Economic and Demographic Factors.”

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