Grant County, WV

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Filled with opportunities for hiking, rock climbing, and countless other outdoor-recreation activities, Grant County is described in tourism materials as the “Heartbeat of the Potomac Highlands.” Many long-time residents of this mountainous Appalachian county would agree that the land exudes a sense of health and vitality.

But they would also say that life in the county can be hard, with significant barriers keeping residents from pursuing optimal health and well-being. That is the dichotomy of Grant County: a place rich in natural resources and nationally recognized wilderness areas, yet lacking in some of the basic elements known to contribute to good health, such as reliable access to transportation and healthy food, and steady employment.

In this county spanning 480 square miles, the poverty rate is higher, and the median income lower, than in the nation; a greater percentage of residents live with a disability; and the population skews more toward older adults. Despite the resplendent landscape that beckons folks to explore the great outdoors, maintaining good health is a challenge for residents.

Grant County is among the ten percent of Appalachian counties—and one of the eight counties in West Virginia—identified as a Bright Spot. It performed better than expected on 12 out of 19 health outcome measures. Most notably, the county performed better than expected on the following measures:

These better-than-expected results are likely influenced by local conditions and initiatives created by the county to improve overall well-being. For instance, field research indicates that committed local health providers and sustained cross-sector collaboration may have played a major role in the county’s health. Grant County residents have also pooled resources to target specific issue areas such as care and social service supports for seniors, and creating transportation networks to overcome the isolation and rugged terrain that can be barriers to health.

Grant County’s classification as a Bright Spot means that, on average, the county performed better than expected on a number of health outcome measures, given its characteristics and resources—that is, the socioeconomics, demographics, behaviors, health care facilities, and other factors that influence health outcomes. It does not mean that all Grant County residents enjoy excellent health. Like other counties with limited resources, Bright Spot counties face many challenges to attaining good health outcomes. But Grant County’s performance does indicate that certain county conditions or programs may be helping generate better-than-expected outcomes—and that other resource-challenged Appalachian counties may benefit from adopting similar initiatives.[1]

County Overview

Grant County represents a nonmetropolitan county in North Central Appalachia. It is one of a cluster of Bright Spot counties in northeastern West Virginia and one of the eight identified in the state as a whole.

Grant County’s abundant natural assets provide a rich array of outdoor-recreation attractions, from spectacular mountain vistas to exceptional trout fishing. The county is home to several nationally recognized attractions, including the Dolly Sods Wilderness Area, Smoke Hole Caverns, and the North Fork Mountain Trail. Located in the western end of West Virginia’s Eastern Panhandle, Grant was designated by the Appalachian Regional Commission as a transitional county in fiscal year 2017. The county was created at the time of the Civil War from neighboring Hardy County and named for General Ulysses S. Grant. The area is rich in history, hosting a variety of historical structures, including Fort Mulligan, one of the few remaining Civil War earthen forts.

Grant County is one of eight North Central Appalachian counties identified as a Bright Spot. Located within an eight-county region called the Potomac Highlands, it has just two incorporated municipalities: Petersburg, the county seat, and Bayard, a former coal mining community. There are nearly three dozen other outlying communities.

The county has maintained a relatively stable population of about 11,800 people. Approximately 98 percent of Grant County residents are white, and 81.9 percent have at least graduated from high school. The estimated median household income in 2014 was $41,039, compared with $56,135 nationally. About 8 percent of county residents receive disability benefits, compared with 5.4 percent nationally; and 17 percent live in poverty, compared with 15.6 percent nationally.[2]

The county’s top employers are in health care (Grant Memorial Hospital, Grant County Nursing Home, and Potomac Highlands Guild), natural resources (Allegheny Wood Products, Inc., Grant County Mulch, Dominion Resources’ Mount Storm Power Station), or the government (the Grant County Board of Education). A significant number of residents continue to farm (fruit, tobacco, and grain) and breed livestock.

A Deeper Look at Grant County: Community Strengths

As in other Bright Spot communities, leaders, organizations, and residents in Grant County are using collaboration and resource sharing to provide a range of health care, public health, and social services. This includes a commitment to supporting low-income residents and sustaining a task force to discuss local challenges and solutions. Strong leadership has helped guide many of the county’s initiatives.

Field work helped identify local practices in Grant County that appear to be contributing to overall health, document effective practices that could be replicated in other counties, and identify promising practices and strategies that should be explored further.[3] Specifically, the research found these characteristics and strategies in Grant County:

• Cross-sector collaboration: Government agencies and emergency services as well as nonprofit organizations work as a unit to benefit the community in several ways. These collaborations are committed to supporting low-income residents. Many of these organizations’ employees pledge their time to support and develop county-based services and events. People serve across several of the groups in collaboration, thereby increasing the flow of information between them.
• Resource sharing: Several initiatives pool resources to provide services targeted to particular population groups, both within the county and adjacent to it. Key areas dependent on resource sharing include: support for youth, support for seniors, transportation access, and substance abuse and prevention education.
• Local providers committed to public health: A network of local providers, spanning acute care, mental health care, and long-term care, work cohesively to provide county residents with comprehensive access to health care. There is a concerted effort to provide these services to all residents, including low-income and medically underserved groups, through thoughtful planning, volunteer work, and donations. Many of these providers are long-term residents who are familiar with, and dedicated to, local health issues.
• Initiatives to combat substance abuse: Recognizing the need to address the threat of substance abuse in the community, Grant County is mobilizing its resources through coalitions and trainings to prevent drug abuse and overdose, as well as engage in harm reduction.

Many of Grant County’s programs fall under four categories: collaboration, resource sharing, local providers committed to public health, and initiatives to combat substance abuse.

Cross-Sector Collaboration

Cross-sector collaboration is part of the county’s DNA and addresses many issues, ranging from the creation of food pantries to address hunger, to the coordination of health fairs to screen for physical health needs. Perhaps the most notable example of this is in the work of the Family Issues Task Force (FITF), established under emergency conditions to deal with the devastating aftermath of the 1985 Election Day floods. Most of the 47 people killed when the Potomac River crested at 22.6 feet were from Grant and Pendleton Counties. Since that time, FITF’s purpose has evolved from guiding post-disaster recovery to coordinating efforts to identify, assess, and respond to local health issues. The FITF brings together leaders from diverse organizations, including the county health department, Community Action, the library board, the arts council, United Methodist Family Services, Community Education Outreach Services, local schools, the Commission on Aging, the Potomac Highlands Guild, and Grant Memorial Hospital.

The oldest and most extensive collaboration is Community Education Outreach Services (CEOS), which has five separate clubs in the county. According to the West Virginia University Extension Service website, the members of CEOS have helped “strengthen individuals, families, and communities across the state of West Virginia since 1914.” In collaboration with the extension service, CEOS develops programs centered on service, continuing education, and leadership development. In Grant County, CEOS members coordinate the health fair offered to county residents and collaborate with the county courthouse to hold a breast cancer awareness event.

There are considerable cross-sector collaboration efforts that aim to support youth. Grant County schools work with the extension service to hold the Energy Express program and teach a nutritional science course. The schools also collaborate with Grant Memorial Hospital to offer a course on careers in health. (To benefit residents of all ages, Grant Memorial also collaborates with a local, privately owned pharmacy to provide blood tests in support of its diabetes prevention program, which is sponsored by the federal Centers for Disease Control and Prevention (CDC).)

The Prevention, Intervention, Treatment, Anti-Stigma, and Recovery (PITAR) coalition is a fairly new cross-sector collaboration organized to address behavioral and mental health issues. The coalition brings together people from the criminal justice system, treatment organizations, and patient advocacy groups. According to Dr. Raj Masih, regional health promotion and wellness coordinator for the Potomac Highlands Guild, the group focuses on solutions and actions to help people in various stages of need.

Resource Sharing

Grant County uses collaboration and resource sharing in almost all of its efforts to improve the health of residents and the larger community. The county funnels pooled resources into support for its youth and elderly populations, transportation support, and meal distribution.

Recently, the Grant County Commission donated land, funding, and services worth about $125,000 for construction of a new multipurpose center for the county’s elderly population. The top two outcome measures on which Grant County does better than expected are stroke mortality and heart disease hospitalization. These outcomes may be related, in part, to the extra support the county provides to its senior population.

Grant County has also partnered with the 4-H national youth development and mentoring program for decades, with about 200 youth formally enrolled in multiple 4-H programs. Young people involved in 4-H typically study agriculture and related environmental issues in ways that incorporate an element of physical activity.

The Eastern West Virginia Community Action Agency partners with Warm the Children, serving as a social service referral center for more than 800 economically distressed families in the county, providing children with winter coats, gloves, and boots. It reflects a local commitment to supporting the well-being of residents in the most vulnerable segments of the county’s population.

Transportation

Transportation is a real challenge for some Grant County residents. Steep, unpaved roads make parts of the county hard to reach when the weather is bad. Reaching residents of Mt. Storm during a medical emergency can be especially difficult. Although there is a helipad at Grant Memorial and emergency helicopter services are available, it can still be a challenge to access the more remote areas of the county. Reaching these areas as fast as possible is the goal of the county’s strategic ambulance location plan and its “grassroots mapping system.” By stationing ambulances at strategic locations around the county and incorporating local knowledge about roads and geography (often provided by hunters and fishermen) into its mapping system, Grant County has been able to steadily improve its emergency response times.

The health department also subsidizes transportation for women who need to travel to a neighboring county for cancer treatment, using a Susan G. Komen grant to help cover the costs of transportation, lodging, and incidentals. Church group volunteers often provide transportation for medical appointments and pharmacy visits.

The county still faces serious health-related transportation challenges, yet coordinated grassroots efforts use local resources to address these challenges as effectively as possible.

Food

For 28 years, the Commission on Aging Family Services has offered comprehensive support for seniors throughout the county. Major services include a nutrition program that offers meals at locations in Petersburg, Mt. Storm, Maysville, and Dorcas, and as well as transportation to the four meal locations. The commission also provides in-home services to assist with food preparation, personal care, and light housekeeping, and transportation assistance for medical appointments, shopping, and banking. Approximately 47 people now receive in-home services, and approximately 142 receive meals at the four nutrition sites each month.

Local Providers Committed to Public Health

Grant County has a network of local providers offering comprehensive health care services. These providers include Grant Memorial Hospital, a county health department, a behavioral health facility (the Potomac Highlands Guild), a 110-bed nursing home, an outpatient Veterans Health Administration clinic, and private physicians. While their primary focus is on health care services, these providers are committed to using resources to addressing burgeoning health issues, such as obesity and opioid abuse.

Grant Memorial Hospital is a county-owned critical access hospital established in 1958. With more than 350 employees and a professional medical staff of approximately 15, it provides 25 acute-care beds and 20 long-term and/or skilled-nursing beds, and offers a variety of services, such as ob-gyn; pediatrics; general surgery; general orthopedics; internal, family, and emergency medicine; imaging services; and temporary coverage in ophthalmology and urology. The hospital also conducts a community health needs assessment to guide and support needed population health initiatives identified by residents.

“We recognized several years ago that we had to go beyond the four walls of the hospital,” says Grant Memorial CEO Mary Beth Barr. She adds that the hospital’s mission is to serve the entire community, even if the preventive services provided are not always reimbursed. One example of this commitment to community health is Grant Memorial’s monthly “Healthy Saturdays” health fair, at which staff and volunteers perform, on average, 300 blood panel workups at a nominal cost of about $35 each. Every Healthy Saturday event features both general health information and information on a specific topic (e.g., diabetes, obesity, and congestive heart failure).

Grant Memorial also offers a diabetes prevention program certified by the CDC. One of only four such programs in the state, it provides free counseling and support to prediabetic patients to help keep them from becoming diabetic. A local pharmacy provides hemoglobin A1C tests. The program lasts one year, after which participants “graduate” and receive another year of follow-up support.

Over the years, the hospital has also offered physician and other care provider rotations. The hospital’s openness to teaching has enabled it to offer a wide range of specialty care services.

Providers with the Grant County Health Department and the Potomac Highlands Guild actively focus on meeting residents’ needs outside of the hospital. The health department offers a wide range of clinical, educational, environmental, and emergency preparedness services. It is sometimes the sole provider for low-income residents of the county.

The Potomac Highlands Guild is one of 13 comprehensive behavioral health providers in the state. It operates satellite offices in five Eastern Panhandle counties, including Grant County. Many credit it with being an innovator in addressing the issues of methamphetamine and opioid addiction.

Grant County’s public and private health care providers are committed to making a difference in people’s lives.

Initiatives to Combat Substance Abuse

Substance abuse is a public health issue that the local community is vigilant about— with good reason. West Virginia’s overdose mortality rate, double the national rate, is the highest in the country. The crisis in the county seat of Petersburg is so acute that it is the subject of a documentary film, “Petersburg,” which chronicles how drugs took hold in this small city of 2,500 people (Allott and Allott 2017).

Grant County has launched several initiatives to try to get ahead of this public health battle. The county and local organizations are collaborating to form coalitions; considering needle exchange programs; and offering training in the administration of naloxone, which can rapidly reverse an opioid overdose. The Prevention, Intervention, Treatment, Anti-Stigma, and Recovery (PITAR) coalition[4] is helping coordinate an effort that spans all aspects of addressing addiction, from education to mental health counseling to treatment and recovery services. PITAR comprises upwards of two dozen participating organizations, including the Potomac Highlands Guild, the Russ Hedrick Recovery Resource Center, the Grant County Health Department, and local media organizations. Here is greater detail on some of the organizations and their initiatives:

The Potomac Highlands Guild is the regional agency providing intensive outpatient treatment for substance use disorder. With offices in Petersburg, Moorefield, Romney, Franklin, and Keyser, the guild provides counseling (individual and group) for people with addiction and substance use disorders. It facilitates placement in detox and inpatient rehabilitation programs, and in long-term treatment facilities. Staff are on call 24/7, 365 days a year, to respond to the emergency room for any crisis related to substance use disorders. The guild runs the regional DUI education and treatment program for the DMV, and has an after-hours crisis line to help with issues related to substance use disorders.

Additionally, the guild provides mental health counseling and treatment for people with mental health issues such as depression, anxiety, bipolar disorder, schizophrenia, and post-traumatic stress disorder. Providing assistance in this way can help people deal with mental health issues effectively and avoid using drugs and alcohol to self-medicate.

The Russ Hedrick Recovery Resource Center is a nucleus for recovery activities in the area. The center serves as a drop-in site to help people with substance use disorders get into treatment, begin recovery, and find the resources they need to re-establish their lives. Center coordinator Wade Rohrbaugh and five other certified peer recovery coaches are available to help individuals navigate the pathway through recovery and also serve as a resource for families and loved ones of individuals dealing with addiction issues. The center facilitates 12-step recovery meetings almost daily. Additionally, it provides training in administering naloxone to reverse opioid overdose to the general public and to first responders through the West Virginia Office of Emergency Management Services. To date, more than 2,800 people have used the center’s services, and more than 200 people have been trained in naloxone administration.

The Grant/Hardy Recovery Group is a driving force behind the recovery movement in Grant County. The group conducts 56 recovery meetings a month in Petersburg, Moorefield, and Franklin. The meeting groups include Narcotics Anonymous, Nar-Anon, Smart Recovery, and Dual-Recovery Anonymous.

The Grant County Health Department has also approved a harm reduction program and is considering providing training in administering naloxone for overdoses.

Grant County schools are actively engaged in promoting healthy behaviors and preventing substance abuse among students. Two effective programs include Too Good for Drugs and Students Against Destructive Decisions (SADD). Too Good for Drugs seeks to educate students from elementary school through high school about the dangers of drugs, the risks of addiction, and the long-term consequences of substance abuse. SADD is a student-led effort to discourage behaviors such as smoking, abusing drugs and alcohol, and having unprotected sex. The school system also offers a class on healthy eating, as well as a health-careers club.

Creating a Culture of Health in Grant County

Grant County’s actions—whether they’ve evolved organically through a volunteer effort or been established through the work of a coalition or health care system—indicate that county leaders and residents place a high value on health. This is reflected in the range of assistive transportation services offered county-wide, including the emergency medical transport subsidized at a cost of $200,000 per year. The level of investment of money and time in holding county-wide health events, as well as in providing prompt emergency response and transport, conveys that health is important and that protecting it is a shared responsibility.

This message is reinforced by the sustained focus on support for youth, seniors, and those battling addiction. Grant County is putting resources into educating its young people about healthy behaviors and giving them opportunities to practice those behaviors. Seniors are provided with fitness opportunities and, when needed, communal and in-home meals, counseling on Medicare plans, and subsidized assistance with transportation. This support for seniors may contribute to Grant’s better-than-expected rates of stroke mortality and heart disease mortality.

Grant County has put together a wide range of services that address the health of both body and mind, and community leaders continue to develop innovative ways to help residents live healthy lives.

References

• Allott, Daniel and Jordan Allott. 2017. “The Race to 2020: The people and places that will define a presidency.” Washington Examiner. Accessed May 15, 2018.
• Centers for Disease Control and Prevention, National Center for Health Statistics. 2017. Drug Overdose Deaths in the United States, 1999–2016.
• Charleston Gazette-Mail. 2015. “Video: Gazette-Mail reporters, photographers reflect on covering 1985 flood.” Charleston Gazette-Mail, November 4, 2015. Accessed May 15, 2018.
• Grant County Commission on Aging Family Services. 2014. “Our History.” Accessed May 15, 2018.
• Grant County West Virginia Convention and Visitors Bureau. 2016. “Grant County: The Heart Beat of the Potomac Highlands.” Accessed May 15, 2018.
• Holmes, G. Mark, Nancy M. Lane, Thomas A. Arcury, Michael L. Schawlbe, Randy Randolph, John Frank, Sharita Thomas, et. al. 2018. Identifying Bright Spots in Appalachian Health: Statistical Analysis. Washington, D.C.: Appalachian Regional Commission.
• Marshall, Julie L., Logan Thomas, Nancy M. Lane, G. Mark Holmes, Thomas A. Arcury, Randy Randolph, Pam Silberman, et al. 2017. Health Disparities in Appalachia. Washington, D.C.: Appalachian Regional Commission.

Appendix: Grant County Data

Table 36: Grant County Characteristics

Characteristic	Grant County	United States
Population, 2010–2014	11,829	314,107,084
Percent population change, 2010–2015	-1.40%	4.10%
Median age, 2015	44.9	37.8
Percent of persons over age 65, 2015	23.00%	14.90%
Median household income, 2014	$41,039	$56,135
Per capita income in past 12 months (in 2015 dollars), 2011–2015	$20,052	$28,930
Unemployment rate, 2014	7.7%	6.2%
Percent persons in poverty, 2014	17.0%	15.6%
Percent white alone, 2015	97.70%	77.10%
Percent black alone, 2015	1.00%	13.30%
Percent adults with at least some college, 2010–2014	33.74%	63.27%
Distance to nearest large population center from county center	Fairmont, WV – 84.8 mi.	N/A
ARC designations, fiscal year 2017	Transitional North Central Appalachia	N/A

Source: These data are compiled from the U.S. Bureau of Labor Statistics, Local Area Unemployment Statistics, 2014, and the U.S. Census Bureau American Community Survey Selected Social Characteristics, General Economic Characteristics, Demographic and Housing Characteristics, and Educational Attainment Tables for years 2010–2014 and 2011–2015.

Table 37: Grant County Key Informants

Name	Location	Title	Organization	Interview Date
Barb Carr	Public Library	Librarian	Grant County Public Library	5/8/2017
Dr. Raj Masih	Russ Hedrick Recovery Resource Center	Regional Health Promotion and Wellness Coordinator	Potomac Highlands Guild, Inc.	5/8/2017
Gina Hinkle	Public Library	Office Coordinator	WIC Nutrition Program	5/8/2017
Aimee Cardot	Community Action	Grant County Community Development Director	Eastern WV Community Action Agency	5/8/2017
Rick Smith	Community Action	Executive Director	Eastern WV Community Action Agency	5/8/2017
Sandy Glasscock	Health Department.	Nurse Director/Administrator	Grant County Health Department	5/9/2017
Peggy Bobo-Alt	911 Center	Director	911 / Office of Emergency Services	5/9/2017
Alex Coffman	Extension Office	4-H / Extension Agent	WVU Extension Service	5/9/2017
Teresa Nazelrodt	Extension Office	Secretary	WVU Extension Service	5/9/2017
Rich Cardot	Presbyterian Church Petersburg	President	Grant County Ministerial Association	5/10/2017
Mary Beth Barr	Grant Memorial	CEO	Grant Memorial Hospital	5/10/2017
Charlotte Reel	Grant Memorial	Dietary Manager	Grant Memorial Hospital	5/10/2017
Gayann Veach	Grant Memorial	Chief Quality Officer	Grant Memorial Hospital	5/10/2017
Paula Combs	Grant Memorial	Director, Social Services	Grant Memorial Hospital	5/10/2017
Teresa Snyder	Grant Memorial	Director, Imaging Services	Grant Memorial Hospital	5/10/2017
Julie Kesner	Grant Memorial	Community Resources Coordinator	Grant Memorial Hospital	5/10/2017
Malinda Turner	Grant Memorial	Compliance and Privacy	Grant Memorial Hospital	5/10/2017

Table 38: Grant County Health Outcomes – Actual vs. Predicted

Outcome Measure	Actual	Predicted	Percentage Difference (negative = better)
Stroke mortality per 100,000 people, 2008–2014	28.45	47.73	-40.4%
Heart disease hospitalizations per 1,000 Medicare beneficiaries, 2012	36.00	60.34	-40.3%
Injury mortality per 100,000 people, 2008–2014	37.42	58.87	-36.4%
Cancer mortality per 100,000 people, 2008–2014	130.53	184.16	-29.1%
Years of potential life lost, 2011–2013	7,387	9,550	-22.6%
Opioid prescriptions as a percent of Part D claims, 2013	4.28	5.52	-22.5%
Percentage of excessive drinkers, 2014	10.5%	12.7%	-17.3%
Poisoning mortality per 100,000 people, 2008–2014	14.65	17.67	-17.1%
Suicide mortality per 100,000 people, 2008–2014	13.95	16.38	-14.8%
COPD mortality per 100,000 people, 2008–2014	48.11	56.18	-14.4%
Average Medicare condition score, 2013	0.87	0.99	-12.0%
Percentage of Medicare beneficiaries w/ depression, 2012	15.20%	16.08%	-5.5%
Percentage of obese adults (>30 BMI), 2012	36.90%	36.74%	0.4%
Mentally unhealthy days per month per person, 2014	4.60	4.56	0.8%
Infant mortality per 1,000 births, 2008–2014	7.76	7.63	1.6%
Heart disease mortality per 100,000 people, 2008–2014	226.11	216.66	4.4%
Physically unhealthy days per month per person, 2014	4.70	4.48	4.9%
Percentage of adults with diabetes, 2012	16.1%	14.6%	10.2%
Low birth weight births (<2,500g) per 1,000 births, 2007–2013	9.40	8.49	10.7%

Notes:

• Percentage Difference = 100 * [ (Actual / Predicted) – 1]
• Green = County value was better than predicted

For details on the outcome measures, see the data files accompanying the report Identifying Bright Spots in Appalachian Health: Statistical Analysis.

Table 39: Grant County Health Drivers vs. National Median

Driver Measure	Lower is Better?	National Median	Grant County
Air pollution (average daily particulate matter 2.5), 2011	Yes	11.87	13.14
Average travel time to work in minutes, 2010–2014	Yes	22.82	25.75
Chlamydia incidence rate per 100,000, 2013	Yes	287.16	169.26
Dentists per 100,000 population, 2014	No	37.45	42.74
Economic index, fiscal year 2017	Yes	108.79	126.71
Full-service restaurants per 1,000, 2012	No	0.68	0.68
Grocery stores per 1,000 residents, 2012	No	0.20	0.25
Median household income, 2014	No	$45,226.00	$41,039.00
Mental health providers per 100,000 population, 2015	No	80.00	68.49
Percentage of adults currently smoking, 2014	Yes	17.8%	22.1%
Percentage of adults not physically active, 2012	Yes	27.7%	38.4%
Percentage of adults with at least some college, 2010–2014	No	56.3%	33.7%
Income inequality ratio,[5] 2010–2014	Yes	4.4%	3.9%
Percentage of diabetics with A1C testing, 2012	No	85.4%	78.6%
Percentage of doctors who e-prescribe, 2014	No	65.0%	40.0%
Percentage of eligibles enrolled in SNAP, 2014	No	78.0%	83.0%
Percentage of households with income below poverty, 2014	Yes	15.8%	17.0%
Percentage of Medicare women with recent mammogram, 2013	No	61.0%	65.0%
Percentage of population with access to places for physical activity, 2011 and 2014	No	61.9%	51.3%
Percentage of total population in social assistant jobs, 2013	N/A	0.01%	0.02%
Percentage receiving disability OASDI and/or SSI, 2014	Yes	5.4%	7.9%
Percentage spending >30% of income on housing, 2010–2014	Yes	29.0%	18.7%
Percentage w/ no car, low access, 2010–2014	Yes	19.7%	18.9%
Primary care physicians per 100,000 population, 2013	No	48.54	51.02
Social associations per 10,000 population, 2013	No	12.68	15.31
Specialist physicians per 100,000 population, 2013	No	25.93	25.36
Students per teacher, 2013–2014	Yes	14.13	—
Teenage births per 1,000, 2007–2013	Yes	39.96	50.32
Uninsured rate for people under 65, 2013	Yes	17.24	19.09

Notes:

• Green = County value was better than national median

For details on the driver measures, see the data files accompanying the report Identifying Bright Spots in Appalachian Health: Statistical Analysis.