Kentucky did poorly in the latest national survey of well-being, but the state's 5th Congressional District fared even worse.
The district covering Eastern and Southern Kentucky ranked the lowest among 434 nationwide included in a survey of people's perception of well-being.
The survey assessed people's emotional and physical health; behavior that affects health, such as smoking or exercising; job satisfaction and access to basic needs, including food and housing; and their outlook on life.
It's not the first time the region has finished at the bottom of the index compiled by the Gallup polling organization and Healthways, a Tennessee-based company that provides services to improve well-being.
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Donna Pace sees the reality of the survey every day. She heads the Harlan County Community Action Agency, which has assistance programs to help people with heating, food and other needs. Requests for services have increased as jobs in the regional coal industry plummeted the last two years.
"We're seeing people we've never seen before, who never had to ask for help," Pace said.
The state as a whole ranked 49th in the well-being index, ahead of only neighboring West Virginia and just behind Mississippi. That was the same spot Kentucky has held each year but one since the index started in 2008, when the state finished 48th.
There are a lot of factors that drive down Kentucky's ranking, including relatively high poverty, the top smoking rate in the nation, lots of uninsured people and high rates of depression, drug abuse, obesity and other health problems.
"Our health status is dismal in Kentucky," said Dr. Stephanie Mayfield, commissioner of the state Department of Public Health.
Problems that make for a poor showing in the well-being survey are even more pronounced in the state's eastern coalfield.
In Breathitt County, for example, the percentage of residents with adequate access to exercise opportunities was 25.1, compared to 84.8 percent in counties with the best access, according to a survey released last month by the University of Wisconsin Population Health Institute. The county's obesity rate was 40 percent; the rate among top performers was less than 25.3 percent.
In Martin County, 37.4 percent of people smoked; U.S. counties with the lowest rates were under 13.8.
Harlan County scored 13,054 in a measure of years lost to premature death, with the best U.S. counties under 5,316. In Clay County, there were 266 preventable hospital stays per 1,000 Medicare enrollees, compared to 46 among the top-performing counties, the study found.
Eastern Kentucky has "profound health disparities," said Louise Howell, who formerly headed Kentucky River Community Care and now serves as a consultant.
The problems build on each other; people in poor health can't find or keep jobs, feeding depression and related problems.
There has been an increase in depression and substance-abuse addiction in the region with the downturn in the coal industry, said Howell and Ernestine Weems, executive director of the eight-county community mental health program.
"It is very hard to transcend poverty" in the face of physical and behavioral health problems, Howell said.
Against that backdrop, however, an effort is taking root to improve the regional economy, which if successful could improve residents' outlook and other measures of real and perceived well-being.
Gov. Steve Beshear and U.S. Rep. Hal Rogers started the initiative last year. It is called Shaping Our Appalachian Region, or SOAR.
The goal is to involve Eastern Kentuckians in coming up with ideas and plans to diversify and expand the region's economy, then act on those plans.
Rogers, a Republican, and Beshear, a Democrat, recently named an executive committee to oversee the next phase of the initiative, which includes holding a series of public meetings this summer to generate more ideas and greater involvement.
The sense of helplessness among many people in the region complicates the effort to imagine and pursue a better future, said Charles W. Fluharty, who heads the Rural Policy Research Institute and is interim executive director of SOAR.
The context the initiative faces is as challenging as he's seen in 25 years of work with the research institute around the nation, Fluharty said.
In addition to other issues, the region has a history of control by elites and of parochial politics — the opposite of the regional collaboration and development that helps places succeed these days, Fluharty said.
"I think this is the toughest, most difficult region we've worked in, ever," he said.
But Fluharty said there are reasons to be optimistic. There are great assets in the region, and the bipartisan backing of Rogers and Beshear is a key plus, he said. Moreover, many people in Eastern Kentucky have come to realize the coal-dependent region must try a new approach, he said.
An estimated 1,700 people attended the initial SOAR summit in December, and many more have signed on since. Fluharty said he has never seen so many people get involved so quickly in an effort to turn around a region.
"People realize if we've got any chance at all we've got to seize the reins, we've got to diversify the economy," said Dee Davis, president of the Center for Rural Strategies in Whitesburg.
There also are efforts underway through local health departments, community groups and others to improve health in Eastern Kentucky and across the state.
Like SOAR, one ambitious example is just getting underway.
Beshear announced a plan in February, called kyhealthnow, to involve every state-government cabinet and public and private groups in efforts to measurably improve Kentuckians' health over the next five years.
The goal is to cut smoking and obesity rates; reduce the number of people with no health insurance and the number of children with untreated dental problems; and drive down deaths from cancer, cardiovascular disease and drug overdoses.
The strategies include trying to increase the number of dentists in Kentucky, providing health screenings for more people, building more walking and bike paths, getting more people into substance-abuse treatment and pushing laws to ban smoking in public places.
Mayfield, the Department of Public Health commissioner, said the state already has made progress by signing up about 400,000 people for health coverage through the insurance exchange set up under the federal Affordable Care Act.