Sequatchie County, TN

Everybody feels like they’re in it together, and there’s a lot of collaboration and helping each other.
—Beth Delaney, Community Development Director, Southeast Regional Health Office

Referred to as the “Hang Gliding Capital of the East,” Sequatchie County, Tennessee, draws operators of the unpowered aircraft from around the world with its favorable flying conditions and aerial views.

Located in the Sequatchie Valley—which is known for its beautiful landscape and moderate climate—the county is home to a growing number of affluent retirees and urbanites from other states who are attracted to the area’s natural amenities and proximity to Chattanooga. As a result, the county of 14,431 people has grown rapidly, its population rising 28.3 percent from 1990 to 2000 and 24.1 percent from 2000 to 2010.

The county’s many faith-based communities have a strong presence and take an active role in promoting health. Of note is the large Seventh-Day Adventist (SDA) community, whose members are encouraged to eat a mainly vegetarian diet, get regular exercise, avoid tobacco and alcohol, get adequate rest, seek preventive medical care, and make efforts to help preserve the environment. Health is also promoted in the county through school programs, civic groups, and health care services.

Sequatchie County is among the ten percent of Appalachian counties—and one of seven counties in Appalachian Tennessee—identified as a Bright Spot, performing better than expected across 14 of 19 health outcome measures. Most notably, Sequatchie County performed better than expected on the following five measures:

These better-than-expected results are likely influenced by local conditions and initiatives created by the county to improve overall well-being. Field research indicates that retirees, faith leaders, and health care organizations are playing a critical role in improving both the health and economic well-being of the county.

Sequatchie 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 residents here enjoy excellent health. In fact, the county still lags behind national performance on a number of health outcomes. Like other counties with limited resources, Bright Spot counties face challenges to attaining good health outcomes. Sequatchie County’s performance, however, indicates 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

Sequatchie County represents a metropolitan county in South Central Appalachia. It is one of seven Bright Spot communities in Appalachian Tennessee.

Sequatchie County sits in the Sequatchie Valley, just west of the Cumberland Plateau, about 45 minutes from Chattanooga and near the southern Tennessee border.

Once known for coal mining and large agricultural businesses, this 250-square-mile county is rapidly changing. Half of its workforce commutes to jobs outside of the county, and its residents live in five main communities: Dunlap, the county seat; Lone Oak; Brush Creek; Cagle; and Lewis Chapel. Household income in 2014 was $44,111, compared with $56,135 nationally.

Twenty percent of county residents are age 65 or older, compared with 15 percent of the U.S. population. In fact, in Sequatchie retirees are called “half-backers” because many retired from northern states to Florida and then returned halfway back to settle in the county.

Of Sequatchie’s residents, 97 percent are white; less than one percent are black. About 47 percent of adults in the county have at least some college education, compared with 63.3 percent nationally. The unemployment rate in 2014 was 7.4 percent, compared with 6.5 percent regionally and 6.2 percent nationally. And in 2014, just over 18 percent of county residents had incomes below the federal poverty level, compared with 15.6 percent of the U.S. population.[2]

Major highways run through Sequatchie County, giving a large portion of its population ready access to health care services in Pikeville (Erlanger Bledsoe Hospital), Jasper (Parkridge Hospital, formerly Grandview Medical), and Chattanooga (Erlanger, Parkridge East, Kindred, and Memorial Hospitals). Like some other Bright Spot communities—such as Tioga County, New York; Madison County, North Carolina; and Wirt County, West Virginia—Sequatchie has limited medical facilities of its own, but it has access to medical services in adjacent counties that are a short driving distance away.

A Deeper Look at Sequatchie County: Community Strengths

As in other Bright Spot communities, faith leaders, health care organizations, and social service agencies in Sequatchie County are collaborating and sharing resources to provide a range of health care, public health, and social services. These collaborative efforts emphasize the importance of healthy food and provide opportunities to help residents pursue healthy behaviors. Additionally, two groups have a significant impact on how residents view and value health: a steadily growing retiree community whose members have higher income levels, and a very active faith community.

Field work helped identify local practices in Sequatchie 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 Sequatchie County:

• Shared health values among groups: The larger community reflects the shared health priorities of smaller groups. Faith-based groups, most notably, but also the school system and civic groups, are active and invested in the health outcomes of their members. Good nutrition, for example, is a shared health value.
• Collaboration and sharing of resources: A nearly-30-year-old health council includes members from every sector and meets monthly to discuss and address issues impacting the community. Sequatchie’s single regional school campus also promotes a countywide sense of community.
• Access to health services: The efforts of a regional hospital and larger district health department improve access to preventive and acute care. The area’s mental and behavioral health programs work not only to deliver health services in a community setting, but they also serve to integrate social services. Additionally, area employers demonstrate strong support for the health of their employees through wellness and healthy living incentive programs.
• Volunteer engagement: A theme of engagement is noted in many sectors and is made possible in part with the help of a strong retirement community.

Like other Bright Spots communities, Sequatchie County has initiatives and efforts that fall into several overarching categories: leadership, cross-sector collaboration, local providers committed to public health, and an active faith community.

Community Leaders Engaged in Health Initiatives

The field research found strong evidence in Sequatchie County of leaders from all walks of life working to promote health.

For example, the efforts of county officials and residents to get the Erlanger Health System to establish a medical facility in Dunlap reflects the value they place on health. In its first year of operation, Erlanger Sequatchie Valley served 9,000 patients, nearly double the expected number. In 2016, it served 24,000 patients. This level of service suggests not only a need for, but also a strong desire to seek, care and to use local health care resources. The success of the Sequatchie facility prompted local leaders to approach Erlanger again about establishing a larger, regional hospital in Dunlap. Erlanger agreed, and plans are now moving forward. In December 2016, Dunlap city commissioners contributed $10,000 for preliminary work for the new facility.

There are also strong local leaders at the grassroots level who are committed to addressing substance abuse. Churches, schools, and law enforcement are working to provide rehabilitation assistance to residents in need and to reduce risky behaviors in the community.

The local school board has shown strong leadership by endorsing the Coordinated School Health (CSH) program, which was created by the state legislature in 2000 and fully implemented statewide in 2007. It mandates school-based activities in eight areas: health education; health services; nutrition; physical education; healthy school environment; school counseling, psychological, and social services; student, family, and community involvement; and school staff wellness.

CSH’s health-promotion efforts include providing annual student health screenings to identify issues related to obesity, vision, hearing, blood pressure, and dentition; employing educational programs to combat tobacco addiction, bullying, and drunk driving; holding bicycle safety courses; and offering exercise and stress-reduction classes for school employees. It also helps educators get health information into parents’ hands and out into the community. CSH pursues the goal of educating parents by publishing a quarterly newsletter that is sent home to them, and regularly distributing flyers about health-related issues and events in the community. The program also collaborates with the University of Tennessee Extension Service and Step Up Sequatchie to improve exercise facilities and physical education offerings in the schools.

The CSH program is popular with students, parents, and church groups, and its events are well attended. Notably, the Sequatchie County Board of Education has officially expressed support for the state-mandated program.

An influx of affluent retirees into the community in recent decades may also contribute to the number of community leaders who show a shared value for health. These relative newcomers have gotten involved in local business, politics, and civic affairs, bringing their ideas and skills; many have higher levels of education, and perhaps more health-conscious lifestyles. This “in-migration” of a more affluent population also seems to have created new markets for fitness and health care facilities that have benefited, and will continue to benefit, all of Sequatchie County’s residents.

Finally, in Sequatchie County there is strong employer support for employee health. The county’s major employers are the public school system, the Southeast Tennessee Human Resource Agency (SETHRA), Walmart, Mann+Hummel, NHC Healthcare, Bledsoe Telephone Cooperative, and the Sequatchie Valley Electric Cooperative. These employers all provide some level of health insurance or other wellness benefits for their full-time employees. Additionally, the Bledsoe Telephone Cooperative offers weight-loss programs, free flu shots, and 100 percent coverage for preventive care. The Sequatchie Valley Electric Cooperative sponsors an annual senior expo where people age 55 and older can get free health information and free screenings for high blood pressure and cholesterol. SETHRA offers employees a “teledoc” option that allows them to consult with physicians online on a 24/7 basis. The Sequatchie CSH program provides teachers and other school staff with exercise and relaxation classes.

Cross-Sector Collaboration

Cross-sector change agents in the Sequatchie community come from across the county and include residents, public officials, employers, schools, faith-based organizations, members of the health care sector, community-based organizations, and others.

One example is the Sequatchie Health Council, a 40-member group established 28 years ago that includes representatives of local businesses, social service agencies, the county health department, the county commission, schools, local media, medical offices, and the Tennessee Department of Health. Council members meet monthly to identify local health issues and find ways to address them. Past projects have focused on tobacco control, obesity, substance abuse, suicide prevention, and nutrition education. In addition, the group has sponsored many health fairs and health screening events over the years. One of the health council’s recent projects, Step Up Sequatchie: Improve Your Health One Step at a Time, has brought together volunteers who organize events that help people quit smoking, promote healthier eating, and encourage physical activity. The formation and ongoing efforts of the health council and of Step Up Sequatchie are indicators that Sequatchie residents place a high value on health.

The Sequatchie school system and its partners are another valuable health promotion resource. A significant part of this value lies in the work done through the CSH program, which serves the student population, school employees, and, by extension, family members. It may also be a beneficial factor that Sequatchie County’s public schools—elementary, middle, and high—are housed in one location, an arrangement that aids coordination of health promotion efforts within the school system. The centralized schools, as one interviewee suggested, function as a kind of hub for distribution of public health information.

The Sequatchie County schools also attend to the nutritional needs of students by providing free breakfast and lunch, regardless of family income level. In addition, the schools partner with a local food bank to provide free fruits and vegetables that students can take home to their families.

In this small community, the school system serves as a hub for promoting health through preventive screening, physical activity, classroom and public education, and nutrition.

Local Providers Committed to Public Health

In 2014, at the urging of county officials and residents, Erlanger Health System, based in Chattanooga and affiliated with the University of Tennessee College of Medicine, opened a satellite facility—Erlanger Sequatchie Valley—in Dunlap. This facility provides 24/7 emergency services, primary care, and weekly clinics for cardiology, orthopedics, and women’s health. As noted previously, in 2016 Erlanger Sequatchie Valley treated more than 24,000 patients. Given that apparent level of need, the Erlanger system sought regulatory approval to build a regional hospital in Dunlap. Sequatchie County has since issued bonds to finance construction of the new $32.6 million hospital, which will include 25 beds, and a new 3.0 Tesla MRI to provide magnetic resonance imaging services.

Erlanger is also replacing Erlanger Bledsoe, a small “community and safety net” hospital it has operated in Pikeville (Bledsoe County), 20 miles north of Dunlap, since July 2014. The planned $4.3 million Emergency Center will create better access to care for a medically underserved population in the entire Sequatchie Valley, including Bledsoe, Sequatchie, and Grundy Counties. The project is being financed with tax-exempt bonds issued by Bledsoe County, and Erlanger will lease and operate the new facility to repay the bonds.

In the past, the area benefited from care provided by an emergency room in Dunlap associated with the Grandview Medical Center in Jasper (Marion County), and from the Bledsoe facility, which dates to 1971. When Grandview closed the Dunlap emergency room in 2010, Sequatchie residents successfully lobbied Erlanger to establish the Sequatchie Valley facility, a reflection of strong local concern for health.

Erlanger Hospital in Chattanooga, one of the largest public hospitals in the United States, also plays an important role in supporting the community’s health. It provides comprehensive hospital services, including a level-one trauma center, a nationally renowned stroke center, and a shock-trauma intensive care unit. Sequatchie County residents in need of emergency care can get to the facility in 35 minutes by ambulance. The LIFE FORCE Air Medical emergency helicopter service—established by Erlanger in 1988 and now operated under contract by Med-Trans Corp.—has a helipad in Dunlap and can get patients to Chattanooga in minutes. Sequatchie also contracts with Puckett EMS, based in Austell, Georgia, to provide countywide emergency services. These local and regional emergency response resources, in providing access to expedited treatment, may contribute to Sequatchie County’s better-than-expected performance for poisoning mortality, injury mortality, and stroke mortality.

Active Faith Community

Sequatchie County’s faith-based communities take an active role in promoting health. Since 2008, the Sequatchie Ministerial Association, a consortium of 19 local churches, has been providing supplemental social services to the county’s low-income residents. The association helps people pay utility bills, provides a jail ministry, and operates a food bank. For a time, the United Methodist Church in Chapel Hill, Tennessee, provided a physician-staffed free clinic. The United Methodist Church in Dunlap offers yoga and relaxation classes. The Dunlap Seventh-Day Adventist Church hosts the monthly “Dinner with a Doctor” program, which brings medical expertise and advice to the general public.

Sequatchie County’s churches also raise funds for people who need help with medical bills or post-disaster recovery (such as when a tornado struck in November 2016). Several churches operate volunteer programs that provide free transportation to medical appointments.

The school-based CSH program works with church groups to distribute health information (e.g., about health fairs, preventive screenings, exercise programs, and nutrition) to county residents. Sending flyers to congregations is a locally effective way to get the word out.

In particular, the large Seventh-Day Adventist community plays a significant role. There are two SDA churches in Dunlap, and two in surrounding counties. The church also runs a K–12 school in Dunlap that is open to the public. According to estimates, SDA members may account for up to 10 percent of the county population. This is significant not just because of the local health-related activities the SDA church members support—potluck meals for low-income people, Dinner with a Doctor, participation in health fairs—but also because of the health practices promoted by SDA teachings.

Based on the principle that “the body is the temple of the Holy Spirit,” the SDA church advocates the importance of a healthy diet, regular exercise, and avoiding the use of tobacco and alcohol. These pro-health practices are associated with the exceptional longevity of SDA members. But the church not only has a strong internal culture of health; it also embraces the mission of extending this culture into society at large. Locally, resident and SDA leader Charles Cleveland founded Health Education Resources, a nonprofit organization that promotes preventive medicine worldwide.

Another example of the power of faith-based communities to promote health is the Tennessee governor’s recent initiative to partner with churches to support the work of Project Lifeline, a state-sponsored, multi-county addiction recovery program. Project Lifeline was established to reduce stigma related to the disease of addiction and increase community support for policies that provide for treatment and recovery services. It has also been designed to serve as a vital resource in an area overwhelmed by the country’s opioid epidemic.
Taken together, the efforts of faith groups in Sequatchie County affirm the importance of community health and, through practical actions, bolster it.

Creating a Culture of Health in Sequatchie County

Sequatchie County is changing rapidly as both its demographics and its economy shift. A renewed cultural focus on health and well-being is part of that shift, as a broad range of players work to promote the value of maintaining health. This can be seen in the faith-based communities advocating for healthy behaviors, including undertaking physical activity and working toward better nutrition; local organizations addressing substance abuse; and schools offering parents, teachers, and students opportunities to learn about and practice healthy behaviors.

Important evidence of the value Sequatchie County residents place on health is the strong endorsement of the school board for the work of the CSH program in schools. While a state-mandated health promotion effort could have met with local resistance, just the opposite has occurred in Sequatchie. Those interviewed as part of this case study’s field work described the CSH program as popular with students, parents, and church groups.

Like many other employers in the county, the schools provide teachers and other employees with important health benefits in addition to insurance coverage. These benefits included access to wellness programs and opportunities for physical activity. And beyond urging their congregants to live healthier lives, the county’s faith community provide essential health-related supports to individuals and families who need them, including free meals and health care services as well as help with utility bills.

The civic engagement among newly arrived retirees is also benefiting, and will continue to benefit, all of Sequatchie County’s residents. Many of the retirees are active across the county—taking an interest in local issues, joining local churches, and pursuing volunteer opportunities.

The changes that residents of Sequatchie County are likely noticing may be helping to create some better-than-expected health outcomes, and reinforcing the value that the people who live here place on health.

References

• Agency for Healthcare Research and Quality. (2011). Chapter 9: Access to Health Care, 2011 National Healthcare Quality Report. Retrieved from Agency for Healthcare Research and Quality.
• Chandra, A., J. Acosta, K. Carman, T. Dubowitz, L. Leviton, L. Martin, A. Plough, et al. (2016). Building a National Culture of Health. Retrieved from rand.org.
• Egede, L. E. (2006, June). Race, Ethnicity, Culture, and Disparities in Health Care. Journal of General Internal Medicine, 21(6), 667-669. doi:10.1111/j.1525-1497.2006.0512.x
• Ellison, A. (2016, February 09). Hospital CFO Report: 6 common characteristics of hospitals vulnerable to closure. Retrieved July 27, 2017.
• Fessner, Dave. “Erlanger Gets Approval to Build Hospital in Dunlap, Tenn.” Times Free Press, December 13, 2017.
• Holmes, G. Mark, Nancy M. Lane, Thomas A. Arcury, Michael L. Schwalbe, Randy Randolph, John Frank, Sharita Thomas, et. al. 2018. Identifying Bright Spots in Appalachian Health: Statistical Analysis. Washington, D.C.: Appalachian Regional Commission.
• Institute of Medicine (US) Committee. (1990). Medicare: A Strategy for Quality Assurance (Vol. 1). (K. Lohr, Ed.) Washington (D.C.): National Academies Press (US).
• Loma Linda University School of Public Health. (2017, September 1). Findings for AHS-2. Retrieved from Adventist Health Studies
• 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.
• Office of Disease Prevention and Health Promotion. US DHHS. (2017). Healthy People / 2020 Topics & Objectives/ Access to Health Services. Retrieved July 27, 2017.
• Willet, W. (2003). Lessons from dietary studies in Adventists and questions for the future. American Journal Clinical Nutrition, 539S–543S.
• World Health Organization. (2017). The determinants of health.

Appendix: Sequatchie County Data

Table 32: Sequatchie County Characteristics

Characteristic	Sequatchie County	United States
Population, 2010–2014	14,431	314,107,084
Percent population change, 2010–2015	4.90%	4.10%
Median age, 2015	41.7	37.8
Percent of persons over age 65, 2015	19.80%	14.90%
Median household income, 2014	$44,111	$56,135
Per capita income in past 12 months (in 2015 dollars), 2011–2015	$21,818	$28,930
Unemployment rate, 2014	7.4%	6.2%
Percent persons in poverty, 2014	18.70%	15.6%
Percent white alone, 2015	97.00%	77.10%
Percent black alone, 2015	0.80%	13.30%
Percent adults with at least some college, 2010–2014	47.29%	63.27%
Distance to nearest large population center from county center	Chattanooga, TN- 26.4 miles	N/A
ARC designations, fiscal year 2017	Transitional South 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 33: Sequatchie County Key Informants

Name	Location	Title	Organization	Interview Date
Donna Condra	Dunlap	Field Management Director	Department of Health and Human Services	4/24/2014
Stephanie Boynton	Dunlap	Chief Executive Officer	Erlanger Sequatchie Valley Emergency Department	4/24/2017
Rolanda Green	Dunlap	Coordinator School Health	Sequatchie Board of Education	4/24/2017
Karen Shepherd, MD	Dunlap	County Coroner	Sequatchie County	4/25/2017
Jan Frechette	Dunlap	Director	Sequatchie Health Council	4/25/2017
Beth Delaney	Dunlap	Community Development Director	Sequatchie Health Council	4/26/2017
Dave Hodges	Dunlap	Project LifeLine Coordinator, Region 3 South	Franklin Prevention Coalition	4/26/2017

Table 34: Sequatchie County Health Outcomes – Actual vs. Predicted

Outcome Measure	Actual	Predicted	Percentage Difference (negative = better)
Poisoning mortality per 100,000 people, 2008–2014	18.61	28.74	-35.3%
Injury mortality per 100,000 people, 2008–2014	65.05	81.41	-20.1%
Stroke mortality per 100,000 people, 2008–2014	40.50	50.68	-20.1%
Heart disease mortality per 100,000 people, 2008–2014	192.95	232.14	-16.9%
Heart disease hospitalizations per 1,000 Medicare beneficiaries, 2012	56.40	66.31	-14.9%
Suicide mortality per 100,000 people, 2008–2014	14.09	16.55	-14.9%
Opioid prescriptions as a percent of Part D claims, 2013	4.97	5.59	-11.1%
Percentage of obese adults (>30 BMI), 2012	30.0%	33.2%	-9.7%
Years of potential life lost, 2011–2013	9,977	10,992	-9.2%
COPD mortality per 100,000 people, 2008–2014	71.13	76.56	-7.1%
Physically unhealthy days per month per person, 2014	4.80	5.03	-4.6%
Percentage of Medicare beneficiaries w/ depression, 2012	18.10%	18.72%	-3.3%
Percentage of adults with diabetes, 2012	13.30%	13.47%	-1.2%
Mentally unhealthy days per month per person, 2014	4.70	4.73	-0.6%
Average Medicare condition score, 2013	1.02	1.01	1.0%
Low-birth-weight births (<2,500g) per 1,000 births, 2007–2013	10.62	10.39	2.2%
Cancer mortality per 100,000 people, 2008–2014	230.91	222.67	3.7%
Percentage of excessive drinkers, 2014	11.3%	10.8%	4.5%
Infant mortality per 1,000 births, 2008–2014	7.60	7.14	6.4%

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 35: Sequatchie County Health Drivers vs. National Median

Driver Measure	Lower is Better?	National Median	Sequatchie County
Air pollution (average daily particulate matter 2.5), 2011	Yes	11.87	13.63
Average travel time to work in minutes, 2010–2014	Yes	22.82	32.69
Chlamydia incidence rate per 100,000, 2013	Yes	287.16	214.93
Dentists per 100,000 population, 2014	No	37.45	20.41
Economic index, fiscal year 2017	Yes	108.79	122.84
Full-service restaurants per 1,000, 2012	No	0.68	0.35
Grocery stores per 1,000 residents, 2012	No	0.20	—
Median household income, 2014	No	$45,226.00	$44,111.00
Mental health providers per 100,000 population, 2015	No	80.00	20.41
Percentage of adults currently smoking, 2014	Yes	17.8%	23.2%
Percentage of adults not physically active, 2012	Yes	27.7%	35.6%
Percentage of adults with at least some college, 2010–2014	No	56.3%	47.3%
Income inequality ratio,[4] 2010–2014	Yes	4.4%	5.4%
Percentage of diabetics with A1C testing, 2012	No	85.4%	82.8%
Percentage of doctors who e-prescribe, 2014	No	65.0%	86.0%
Percentage of eligibles enrolled in SNAP, 2014	No	78.0%	92.0%
Percentage of households with income below poverty, 2014	Yes	15.8%	18.7%
Percentage of Medicare women with recent mammogram, 2013	No	61.0%	52.0%
Percentage of population with access to places for physical activity, 2011 and 2014	No	61.9%	43.1%
Percentage of total population in social assistant jobs, 2013	N/A	0.01%	—
Percentage receiving disability OASDI and/or SSI, 2014	Yes	5.4%	9.7%
Percentage spending >30% of income on housing, 2010–2014	Yes	29.0%	29.7%
Percentage w/ no car, low access, 2010–2014	Yes	19.7%	0.1%
Primary care physicians per 100,000 population, 2013	No	48.54	20.45
Social associations per 10,000 population, 2013	No	12.68	5.45
Specialist physicians per 100,000 population, 2013	No	25.93	—
Students per teacher, 2013–2014	Yes	14.13	16.03
Teenage births per 1,000, 2007–2013	Yes	39.96	60.42
Uninsured rate for people under 65, 2013	Yes	17.24	16.10

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.