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SUMMARY
Median household income was used as a variable in an explanatory model to generate a new "economic context" for framing the question: why do Appalachian rural counties have a significantly higher cancer mortality burden than non-Appalachian rural counties in Kentucky, Tennessee, and Virginia? Statistical findings revealed that economic context strongly influence the expected link between isolation (degree of rurality) and health outcomes for Appalachian counties in these 3 states. The data demonstrate that in most of the rural counties it is income that has the most substantial contribution in explaining mortality due to all-cause, premature all-cause, and lung cancer mortality.
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FINDINGS
13.1 Based upon rural-urban designations, the Appalachian region of Kentucky and Virginia has more and an increasing percentage of rural or isolated counties (Beale Codes groups 7-9) than the remainder of those states (both over 50%). The percentage of Tennessee counties designated rural is one-quarter of both all state counties and Appalachian counties.
13.2 Appalachian counties have lower average percent of high school graduates, lower median household, median family and per capita incomes, lower average percent of minority population and lower average percent of population over the age of 65 than non-Appalachian counties.
13.3 Average mortality rates from all cancers were higher in Appalachian counties. There is a statistically significant difference for premature death (ages 35-64) from all cancers between Appalachian (163.51) versus non-Appalachian counties (152.92). In non Appalachian counties, rurality was not a significant predictor of all cancer mortality, but it did enter for Appalachian counties.
13.4 However, for the most rural counties, simple Appalachian location does not contribute significantly to our understanding of the differences.
13.5 The most rural Appalachian and non-Appalachian counties (Beale groups 7-9) demonstrate a significant difference between average death rate of Appalachian and non Appalachian counties for lung cancer and premature death from all cancers.
13.6 Variables significantly related to mortality rate were percent high school graduates, percent rural and percent minority.
13.7 For all cancers, median household income and percent minority population are significantly associated with all cancer mortality rates. However, being an Appalachian county has no independent magnifying effect on mortality rate for these most rural counties.
13.8 For lung cancer deaths, education had the dominant explanatory effect for all counties, along with rurality and percent minority. When the most rural counties are examined, income alone differentiates cancer outcome.
13.9 The failure of Appalachian counties to show significantly higher premature cancer death rates once the other variables are controlled is an interesting finding and differentiates premature mortality from the other two cancer mortalities studied.
13.10 Education is important in the tri-state explanation of all cancer mortality and lung cancer mortality; median household income may have a greater effect in the three states for premature mortality for all cancers.
13.11 Our research has shown that small residual effects of Appalachian residence are significant in explaining lung cancer and all cancer mortality.
13.12 One possible contextual factor that may be of interest in the Appalachian setting is the effect of length of residence…it is historically reasonable to assume that Appalachian residents tend to be more settled than elsewhere. This may magnify the effects of community-level socioeconomic variables on residents which may increase mortality rates. Conversely, the community support fostered by this settled lifestyle may have positive effects of the immune system, as suggest in medical research, which would account for the inverse relationship with mortality when other variables are controlled.
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